Impact of Acetabular Labral Tear Location on Patient-Reported Outcomes and Conversion to Total Hip Arthroplasty After Hip Arthroscopy With an 8-Year Minimum Follow-up

Abstract

Background:

Acetabular labral tears are a common cause of hip pain. While larger tear size has been linked to worse outcomes after arthroscopic treatment, the influence of labral tear location remains incompletely understood.

Purpose:

To investigate how labral tear location affects functional outcomes, conversion to total hip arthroplasty (THA), and patient satisfaction after arthroscopy.

Study Design:

Cohort study; Level of evidence, 3.

Methods:

Patients who underwent primary hip arthroscopy were retrospectively sent online surveys at a minimum of 8 years after their surgery. Tear location was classified into superior, anterosuperior, and posterosuperior based on intraoperative findings. Outcomes included patient-reported outcome measures, conversion to THA, Patient Acceptable Symptom State improvement, and overall patient satisfaction. Unadjusted and adjusted logistic regression models were performed to identify potential confounding variables.

Results:

In total, 138 patients were included with a mean ± SD follow-up time of 11.1 ± 2.5 years. There was no significant difference in all postoperative patient-reported outcome measures across tear locations, although posterosuperior tears demonstrated lower mean outcomes as compared with superior and anterosuperior. Labral tear location was also not found to significantly influence rates of Patient Acceptable Symptom State achievement. Satisfaction was similar among superior, anterosuperior, and posterosuperior tear locations. THA conversion occurred in 20.9% of patients and was not independently associated with tear location after adjusting for confounders. Age was the strongest predictor of THA conversion, and tear size was also significant.

Conclusion:

Acetabular labral tear location was not found to be a significant predictor of functional or clinical outcomes after hip arthroscopy. However, while labral tear location was not predictive of conversion to THA, age and tear size were significant predictors of conversion.

Keywords

hip arthroscopy labral tear labral tear location patient-reported outcomes

Acetabular labral tears are one of the most common causes of hip pain in young and middle-aged adults, with a prevalence of 57% in the general asymptomatic population and up to 80% of symptomatic patients with femoroacetabular impingement.³⁵ The acetabular labrum is a triangular fibrocartilage structure located circumferentially around the acetabular rim, and it acts as a seal around the femoral head, which increases mechanical stability while providing joint lubrication and increased load distribution.^3,15 Tears in the acetabular labrum can compromise these normal functions, leading to increased pain levels, altered gait mechanics, and an increased risk for developing osteoarthritis.^2,19,25

For patients who have failed nonoperative treatments, hip arthroscopy is the standard of care for definitive management of symptomatic acetabular labral tears.³⁰ Many studies have shown improvements in patient-reported outcome measures (PROMs) after hip arthroscopy. However, a subset of patients will still require subsequent conversion to total hip arthroplasty (THA), often attributed to osteoarthritis disease progression.^17,30,36,37 Understanding which factors significantly influence patient outcomes and conversion to THA is crucial for optimizing patient selection and managing postoperative expectations.

Previous studies have identified several factors that indicate poor outcomes after hip arthroscopy for the treatment of labral tears, including older age, higher body mass index (BMI), presence of low back pain, and the presence and severity of osteoarthritis.^7,9,20,34 Additionally, large labral tears have been shown to be independent predictors of outcomes after surgery; however, the impact of the location of labral tears has yet to be fully understood.⁴ The acetabular labrum is also heterogeneous in structure, with the thickest portion in the superior and posterior regions and the widest in the anterior and superior regions.²⁷ This region-specific architecture of the acetabular labrum warrants further analysis to determine if certain regions are better suited to handle abnormal biomechanical forces, suggesting that injury patterns will have different impacts on outcomes after surgical treatment.

Under normal circumstances, the concavity of the femoral neck allows for the hip joint to be stressed in multiple planes without impingement of the labrum between the acetabulum and femoral neck, with areas of higher load transmitting larger shear forces to the labrum.¹⁴ Most labral tears occur in the setting of femoroacetabular impingement. In patients with distortions of the femoral neck concavity, such as those seen with hypertrophic cam lesions, pistol grip deformities, or epiphysial growth anomalies, the labrum becomes impinged upon at the endpoints of certain motions.¹⁴ Greater femoral anteversion, acetabular anteversion, and dysplasia increase the reliance on the labrum for support, resulting in a higher likelihood of tearing, most commonly in the superior and anterosuperior regions.^14,15 Positions that place the hips in forced flexion and abduction, such as prolonged sitting on the ground, have been shown to increase the prevalence of posterior labral tears, although these are relatively uncommon.¹⁴ These anatomic differences may translate into different patterns of healing and clinical outcomes.

Given the increasing utilization of hip arthroscopy for the treatment of acetabular labral tears, there is a need for long-term studies evaluating the relationship between labral tear location and clinical outcomes.¹ The purpose of this study is to investigate the long-term PROMs, rates of achieving clinically meaningful outcomes, overall patient satisfaction, and rates of conversion to THA after hip arthroscopy based on where the labral tear was located. Understanding these relationships provides further insight for patient counseling, surgical planning, and optimizing outcomes in hip arthroscopy.

Methods

Data Collection

This study protocol was approved by the institutional review board (2011P000053) with each patient providing consent. This retrospective study was conducted with patients undergoing hip arthroscopy for symptomatic labral tears by a single, high-volume orthopaedic sports medicine surgeon specializing in hip arthroscopy (S.D.M.), with >8 years of arthroscopic hip surgical experience before the first patient was included in this study. All patients with clinical findings indicative of femoroacetabular syndrome (ie, pain; limited range of motion of flexion, adduction, and internal rotation or flexion, abduction, and external rotation) underwent magnetic resonance imaging and at least 3 months of nonoperative therapy to include hip mobility and core-strengthening exercises. Patients whose symptoms did not decrease to a tolerable level were considered for hip arthroscopy. Patients were included if they underwent primary hip arthroscopy from 2002 to 2013, were aged ≥18 years at the time of surgery, and completed an emailed online survey with minimum 8-year follow-up from the index surgery. The surveys included the modified Harris Hip Score (mHHS), Non-arthritis Hip Score (NAHS), Lower Extremity Functional Scale, Hip Outcome Score–Activities of Daily Living (HOS-ADL), Hip Outcome Score–Sports Specific Subscale (HOS-SSS), and International Hip Outcome Tool (iHOT-33), all of which are validated questionnaires to assess for hip symptom severity. Clinically meaningful outcomes were evaluated by rates of achieving the Patient Acceptable Symptom State (PASS) from previously established threshold values at 5 years.^28,31 Overall patient satisfaction was assessed with a binary scale (satisfied vs not satisfied). Patients were considered satisfied if they responded “yes” on the survey to both of the following: (1) if they were happy with their outcomes and (2) if they would choose the procedure again knowing the outcomes. Data on conversion to THA, revision hip arthroscopy, and other secondary surgical procedures were collected through patient surveys and a manual chart review of each patient's electronic medical record.

Patient descriptive data, including age at the time of surgery, sex, BMI, race, and ethnicity, were collected from electronic medical records (Table 1). Preoperative radiographic parameters, including Tönnis grade, dysplasia, and type of femoroacetabular impingement (none, cam, pincer, or combined), were also evaluated from preoperative radiographs (Table 2).

Table 1

Descriptive Characteristics of Study Population Based on Labral Tear Location ^a

	Superior (n = 21)	Anterosuperior (n = 103)	Posterosuperior (n = 14)	P Value
Age, y	33.1 ± 9.5	38.0 ± 11.5	39.3 ± 8.9	.138
Sex				.006
Male	4 (19.0)	57 (55.3)	9 (64.3)
Female	17 (81.0)	46 (44.7)	5 (35.7)
BMI, kg/m²	25.2 ± 5.2	26.1 ± 4.3	26.9 ± 4.1	.562
Race				.834
White	21 (100.0)	99 (96.1)	13 (92.9)
Black	0 (0.0)	1 (1.0)	0 (0.0)
Asian	0 (0.0)	1 (1.0)	0 (0.0)
Other	0 (0.0)	2 (1.9)	1 (7.1)
Ethnicity				.497
Hispanic/Latino	0 (0.0)	4 (3.9)	0 (0.0)
Not Hispanic/Latino	21 (100.0)	99 (96.1)	14 (100.0)
Follow-up, y	12.4 ± 3.4	10.9 ± 2.2	11.3 ± 3.0	.049

Data are reported as mean ± SD or No. (%). Statistical analysis was performed by 1-way analysis of variance for continuous variables and Fisher exact test for categorical variables. Bold indicates P < .05. BMI, body mass index.

Table 2

Clinical and Radiographic Characteristics of Study Population Based on Labral Tear Location ^a

	Superior	Anterosuperior	Posterosuperior	P Value
Tear size, deg	38.6 ± 16.8	73.2 ± 17.4	77.3 ± 20.2	<.001
Tönnis grade				.505
0	18 (85.7)	85 (82.5)	10 (71.4)
1	3 (14.3)	17 (16.5)	4 (26.6)
Not reported	0 (0.0)	1 (1.0)	0 (0.0)
Labral procedure				.059
Repair	7 (33.3)	61 (59.2)	8 (57.1)
Debridement	14 (66.7)	39 (37.9)	6 (42.9)
Not reported	0 (0.0)	3 (2.9)	0 (0.0)
FAI				.259
None	13 (61.9)	35 (34.0)	5 (35.7)
Cam	6 (28.6)	41 (39.8)	4 (28.6)
Pincer	1 (4.8)	13 (12.6)	2 (14.3)
Both	1 (4.8)	11 (10.7)	3 (21.4)
Not reported	0 (0.0)	3 (2.9)	0 (0.0)
LCEA, deg	33.4 ± 6.6	36.6 ± 7.0	36.8 ± 7.4	.169

Data are reported as mean ± SD or No. (%). Statistical analyses were performed by 1-way analysis of variance and Fisher exact test. Bold indicates P < .05. FAI, femoroacetabular impingement; LCEA, lateral center-edge angle.

Patients were excluded for the following: hip dysplasia defined as lateral center-edge angle ≤20° or acetabular inclination >45°, BMI ≥35 kg/m², Tönnis grade ≥2, prior ipsilateral hip arthroscopy, concomitant procedures (eg, periacetabular osteotomy), inflammatory arthritis, avascular necrosis (including Legg-Calvé-Perthes disease), and slipped capital femoral epiphysis.

Tear Classification

Labral tear locations were classified intraoperatively using a clock-face method divided into 5 distinct areas based on the Beck classification system for acetabular cartilage defects (Figure 1).²³ While the Beck classification system originally used zones A to E, these were renamed posteroinferior, posterior, superior, anterior, and anteroinferior, respectively, for the purposes of our study. Tears spanning the posterior and superior regions were classified as posterosuperior, and tears spanning the superior and anterior regions were classified as anterosuperior. Tears spanning >2 consecutive anatomic regions (ie, posterosuperior to superior to anterosuperior) were excluded from the final analysis to minimize the effect of tear size, as tears spanning multiple regions will inherently be larger. Anterior, posterior, anteroinferior, and anterior-to-anteroinferior tears were also excluded for low sample sizes (Figure 2). Tear size was reported in degrees based on the clock-face Beck classification method, with 1 hour being equal to 30°.

Figure 1.

Locations of labral tears. Labral tear locations were extracted from patient operative reports using a clock-face naming convention: superior tears were from 10:00 to 2:00; anterosuperior tears, 12:00 to 3:00; and posterosuperior tears, 8:00 to 11:00. The same naming convention was used for left and right labral tears. Illustration by Nicole Wolf, MS, ©2025.

Figure 2.

CONSORT flow diagram for patient selection. BMI, body mass index.

Abbreviated Surgical Technique

Each operation in this study was conducted by a single, fellowship-trained sports medicine orthopaedic surgeon (S.D.M.). For each procedure,^10,11,29 patients were placed in the supine position on a hip distraction table (Smith & Nephew). Four arthroscopic portals were established: anterolateral, anterior, midanterior, and Dienst.¹³ Labral debridement was performed if the labral tear was considered degenerative, hypoplastic, or isolated to a single anatomic plane involving <50% of the labrum. Labral repair was performed if there was sufficient healthy labral tissue for suture fixation or if the tear extended into the chondrolabral junction. Cam and pincer lesions were addressed with femoral neck osteoplasty, acetabular osteoplasty, or both.

Postoperative Protocol

After surgery, all patients without absolute contraindications were prescribed 81 mg of aspirin daily for 3 weeks for the prevention of deep vein thrombosis. All patients in our study followed the senior surgeon's studied and published 5-phase postoperative protocol.²⁶ The protocol consisted of patients initially ambulating with crutches while maintaining a flat-foot, stiff-leg gait on the operative side for 6 weeks after surgery. Patients were instructed to decrease abnormal stresses to the best of their abilities on the operative site without limping. After 6 weeks, patients could wean off crutches as tolerated and ride an indoor stationary bike. After 10 weeks, patients could advance to using an elliptical trainer and begin light swimming with the use of a buoy board between their legs. At the 4-month mark, patients could begin short-arc leg presses and hamstring curls. Once patients were 6 months out from surgery, they were permitted to gradually resume normal impact activities as tolerated. This protocol was designed to gradually increase motion without overloading the repair.

Statistical Analyses

All statistical analyses were performed in R software (Version 4.3.0; R Foundation for Statistical Computing). Continuous variables were reported as means with standard deviations, while categorical variables were presented as counts and percentages. Pairwise statistical comparisons for conversion to THA were performed with anterosuperior tears serving as the reference group, as this was the most common tear location in our study. For continuous variables such as PROMs, analysis of variance with a post hoc Tukey test and pairwise independent 2-tailed t tests were performed to compare means among groups. Categorical variables, such as conversion to THA and satisfaction, were analyzed by Fisher exact tests to account for smaller sample sizes. A sensitivity analysis was performed to compare satisfaction with PASS threshold achievement percentages. The relationship between tear location and THA conversion was evaluated by unadjusted and multivariable adjusted logistic regression models. The unadjusted analysis examined the crude association between tear location and THA conversion, while the multivariable model adjusted for age, tear size, and Tönnis grade. Odds ratios (ORs) with 95% confidence intervals were calculated, and statistical significance was set at P < .05 for all analyses. An a priori power analysis was performed to determine the minimum sample size needed to detect a minimal clinically important difference of 15.1 points in mHHS among tear location groups at 5 years (G*Power Version 3.1).^27,30 Previous research from the senior author's prospective hip outcome registry demonstrated that mHHS had a standard deviation of 13. A difference in means of 11.4 points was considered the threshold for detecting a 5-year clinically meaningful difference in mHHS, based on previously published studies.^27,30 Assuming these conditions, an alpha level of .05, and unequal distribution of patients across tear locations, a sample size of 12 patients in the posterosuperior and superior groups and 88 patients in the anterosuperior group will provide 80% power (1 –ß error probability).

Results

Patient Descriptive and Baseline Characteristics

Of the 513 patients who underwent hip arthroscopy during the study period, 166 returned completed surveys. Of these, 138 patients met inclusion criteria with a mean ± SD follow-up of 11.1 ± 2.5 years (range, 8.0-19.7 years). Three patients were excluded for a high BMI, 3 had Tönnis grade ≥2, 14 had labral tears spanning >2 anatomic regions, and 8 were excluded for low sample sizes (Figure 2). Patient descriptive and baseline characteristics are reported in Table 1. The mean age was 43.2 ± 11.3 years, with 67% of patients being female. The mean BMI was 26.4 ± 4.3 kg/m² with a mean tear size of 52.1°± 25.3°. Anterosuperior tears were the most observed tears in our cohort (n = 103; 74.6%), followed by superior tears (n = 21; 15.2%) and posterosuperior tears (n = 14; 10.1%).

There was no significant difference in age among groups (P = .138), but there was a significantly higher percentage of female patients in the superior tear group as compared with the anterosuperior and posterosuperior tear groups (P = .006) (Table 1). No significant differences were observed in BMI among groups (P = .786). Follow-up time differed significantly among groups, as patients with superior tears had longer mean follow-up than patients with anterosuperior and posterosuperior tears (12.4, 10.9, and 11.3 years, respectively; P = .049).

Radiographic and Intraoperative Characteristics

Preoperative radiographic and intraoperative characteristics are summarized based on tear location in Table 2. All clinical and radiographic characteristics showed no significant differences among groups, except for labral tear size (P < .001). However, differences in labral tear size are unavoidable from the classification system used, owing to antero- and posterosuperior tears spanning 2 consecutive anatomic regions. In total, 114 patients (82.6%) had no radiographic evidence of hip arthritis and 24 (17.4%) had Tönnis grade 1. Patients were evenly distributed regarding their tear location (P = .377). No significant differences were noted in the presence and type of femoroacetabular impingement across tear locations (P = .259). An overall 76 patients (55.1%) underwent labral repair while 59 (42.8%) underwent labral debridement. There were no statistically significant differences in rates of labral debridements versus labral repairs for the 3 tear locations of interest (P = .059).

Functional Outcomes and PASS

Patients did not show any statistically significant difference in long-term mean outcomes across all PROMs based on tear location (Table 3). At final follow-up, mHHS scores were 80.6 ± 17.5 for posterosuperior tears, 88.3 ± 12.4 for anterosuperior, and 88.8 ± 12.7 for superior (P = .20). Similar patterns were observed for NAHS (P = .27), Lower Extremity Functional Scale (P = .14), HOS-ADL (P = .38), HOS-SSS (P = .17), and iHOT-33 (P = .15) at final follow-up. Similarly, PASS achievement did not differ significantly among tear locations for mHHS (71.4% for superior, 65.7% for anterosuperior, and 53.8% for posterosuperior, P = .575), NAHS (P = .933), HOS-ADL (P = .991), and iHOT-33 (P = .135).

Table 3

Clinical Outcomes Based on Labral Tear Location ^a

	Superior	Anterosuperior	Posterosuperior	P Value
mHHS	88.8 ± 12.7	88.3 ± 12.4	80.6 ± 17.5	.203
NAHS	86.6 ± 16.2	87.5 ± 12.3	80.0 ± 18.7	.270
LEFS	72.1 ± 9.7	70.6 ± 11.1	63.6 ± 17.0	.114
HOS-ADL	91.9 ± 10.5	90.6 ± 10.9	85.9 ± 16.3	.375
HOS-SSS	83.1 ± 22.7	81.3 ± 20.4	68.2 ± 29.0	.171
iHOT-33	80.7 ± 23.6	76.1 ± 21.2	63.9 ± 28.0	.145
PASS
mHHS	15 (71.4)	65 (65.7)	7 (53.8)	.575
NAHS	14 (66.7)	66 (66.7)	8 (61.5)	.933
HOS-ADL	18 (85.7)	86 (86.0)	11 (84.6)	.991
iHOT-33	13 (61.9)	41 (41.0)	4 (30.8)	.135
Satisfaction	83 (80.6)	17 (81.0)	10 (71.4)	.718

Data are reported as mean ± SD or No. (%). Mean PROM values and percentage of patients achieving PASS are based on tear location. Statistical analysis was performed with 1-way analysis of variance for comparing mean PROMs and a Fisher exact test for PASS achievement. No significant differences were found among tear location groups (all P > .05). HOS-ADL, Hip Outcome Score–Activities of Daily Living; HOS-SSS, Hip Outcome Score–Sports Specific Subscale; iHOT-33, International Hip Outcome Tool; LEFS, Lower Extremity Functional Scale; mHHS, modified Harris Hip Score; NAHS, Non-arthritis Hip Score; PASS, Patient Acceptable Symptom State; PROM, patient-reported outcome measure.

THA Conversion

The overall THA conversion rate was 20.3% (28/138 patients) with a mean time of 6.1 ± 4.6 years to conversion after initial hip arthroscopy. THA conversion rates were not significantly different across locations, with THA conversion rates of 23.3% (24/103) for anterosuperior tears, 21.4% (3/14) for posterosuperior tears, and 4.8% (1/21) for superior tears (P = .12). In the unadjusted logistic regression model, superior tears were 85.2% less likely to require conversion to THA (OR, 0.148; 95% CI, 0.008-0.767; P = .069) as compared with anterosuperior tears. While posterosuperior tears were 18.5% more likely to require conversion to THA, this was not statistically significant (OR, 1.185; 95% CI, 0.304-3.883; P = .789) versus anterosuperior tears.

In our multivariate model, the adjusted ORs showed notable changes from the unadjusted estimates (Table 4). After adjusting for age, tear size, and Tönnis grade, there was no difference in the odds of conversion to THA. For superior tears as compared with anterosuperior tears, the adjusted OR was 1.15 (95% CI, 0.14-11.17; P = .886), and for posterosuperior tears, the adjusted OR was 0.34 (95% CI, 0.04-2.14; P = .255). Age emerged as the strongest predictor, with each additional year of age at the time of surgery resulting in a 5.2% increased adjusted odds for conversion to THA (OR, 1.05; 95% CI, 1.01-1.1; P = .012). From this finding, a 10-year age difference would correspond to 66% higher odds in eventual conversion to THA. Additionally, tear size was an independent predictor of conversion to THA, with 5% increased odds for every additional degree in tear length (OR, 1.05; 95% CI, 1.02-1.09; P = .006). Tönnis grade was not a significant predictor for conversion to THA (OR, 2.27; 95% CI, 0.89-6.02; P = .086).

Table 4

Odds Ratio of Conversion to THA ^a

THA Conversion	No. (%)	Unadjusted OR (95% CI)	P Value	Adjusted OR (95% CI)	P Value
Anterosuperior	24 (24.0)	Reference	—	Reference	—
Superior	1 (4.8)	0.148 (0.008-0.767)	.069	0.335 (0.041-2.136)	.255
Posterosuperior	3 (23.1)	1.185 (0.304-3.883)	.789	1.145 (0.141-11.168)	.886

Unadjusted and adjusted odds ratios with 95% confidence intervals comparing anterosuperior and posterosuperior tears against superior tears (reference group). Adjusted odds ratios account for age, tear size, and Tönnis grade. P values were calculated by multivariable logistic regression with statistical significance of P < .05. OR, odds ratio; THA, total hip arthroplasty.

Patient Satisfaction

The overall patient satisfaction rate in our study was 79.7% (110/138). Satisfaction across all groups was similar, with superior tears having the highest satisfaction at 81.0%, followed by anterosuperior at 80.6% and posterosuperior at 71.4% (P = .718) (Table 3). To assess the validity of using 5-year PASS thresholds at an extended follow-up, we performed a sensitivity analysis comparing PASS achievement rates with patient satisfaction. Overall, patient-reported satisfaction rates were 13.0 percentage points higher than their composite PASS achievement rates (77.7% vs 64.6%). This pattern was consistent across tear locations, with a 9.6–percentage point difference for superior tears (81.0% satisfaction vs 71.4% composite PASS), 15.8–percentage point difference for anterosuperior tears (80.6% vs 64.8%), and 13.7–percentage point difference for posterosuperior tears (71.4% vs 57.7%). Among individual PROMs, HOS-ADL demonstrated the closest alignment with satisfaction (mean difference, 7.8%), while iHOT-33 showed the largest disconnect (mean difference, 33.1%).

Discussion

Regarding labral tear location overall, there were no significant differences among patients in long-term PROMs, PASS achievement, conversion to THA, or patient satisfaction. These findings are promising as previous studies have reported that patients undergoing hip arthroscopy typically report significantly improved functional outcomes postoperatively, as well as minimal complication rates and high rates of survivorship.^6,7,16,21,24 The present study, with a minimum 8-year follow-up, adds to the growing body of literature demonstrating significantly improved long-term outcomes for hip arthroscopy, finding overall satisfaction of roughly 80%. These results provide evidence that differences in labral tear locations should not be a contraindication for hip arthroscopy.

The major finding of this study was that patients with anterosuperior, superior, and posterosuperior tears all demonstrated similar postoperative PROM scores at a minimum 8-year follow-up, suggesting that anatomic tear location alone is not a reliable indicator of postoperative functional outcomes. This finding aligns with existing evidence in the broader orthopaedic literature demonstrating that anatomic variables often have limited correlation with functional outcomes. With regard to shoulder labral tears, Houck et al¹⁸ performed a study of how tear location affects physical examination findings before surgery. They found that tear locations failed to show differences in minimal clinically important difference and were correlated with only small differences in range of motion. Additionally, meniscal tears showed no significant difference in outcomes after surgery in terms of tear patterns (horizontal vs radial) and tear locations (anterior horn, body, or posterior horn).¹²

Recent long-term outcome studies have demonstrated the durability of hip arthroscopy beyond the midterm 2- to 5-year follow-up periods. In a 10-year retrospective study, Domb et al⁸ found that 77.8% of patients met PASS for mHHS, 63.2% for NAHS, and 55.6% for HOS-SSS, consistent with the values described in our study. Additionally, these patients reported a 23.8% conversion to THA at a mean 41.5 months, highlighting the ability for arthroscopic labral repair to restore function and prevent or delay THA.⁸ With our 8-year minimum and 11.1-year mean follow-up, these outcomes are valuable for establishing realistic long-term patient expectations and guiding surgical indications.

PASS achievement rates were similar among the cohorts, indicating that patients achieve relatively similar results after surgery for all tear locations included in this study. Given the retrospective nature of this study and the lack of preoperative PROMs, PASS achievement was one of the main outcomes in determining a successful improvement. While all tear location groups achieved >84% PASS achievement for HOS-ADL, rates for iHOT-33 had a wider range, at 31% for posterosuperior, 41% for anterosuperior, and 62% for superior. This variation in PASS rates across PROMs has been described in the literature, with a systematic review by Levy et al²² finding that overall PASS after hip arthroscopy was 88% for mHHS but far harder to achieve for other scales, with only 25% and 30% of patients achieving PASS for HOS-ADL and HOS-SSS, respectively. Although our study found that more patients achieved PASS for HOS-ADL as compared with other PROM scales, it highlights the complexity of measuring outcomes in regard to which motions and activities show the most improvement after surgery. Additionally, from the sensitivity analysis, the consistently higher satisfaction relative to PASS achievement suggests that 5-year PASS thresholds may be too conservative at a minimum 8-year follow-up period, with patients self-reporting higher levels of satisfaction than the PASS thresholds across all studied PROMs.

Furthermore, labral tear location was not found to significantly influence conversion to THA rates; however, patient age at surgery was the strongest independent predictor of conversion to THA, with the odds of conversion to THA increasing by 5.2% for each additional year of age at index surgery. This trend is supported by other studies in the literature, as exemplified by an insurance database study by Tiao et al³³ that retrospectively studied 5048 patients and identified age and preexisting osteoarthritis as significant predictors of THA conversion; specifically, patients aged 41 to 50 years and those aged 51 to 60 years were >3 and 6.5 times more likely to undergo conversion to THA as compared with patients aged <40 years. Patients <40 years old had a low rate of conversion, with an overall THA conversion rate of 2.7%. A similar insurance database study by Schairer et al³² found a similar trend, with patients <40 years old having significantly lower rates of conversion to THA as compared with patients aged 60 to 69 years. It also identified osteoarthritis and obesity as independent predictors of THA conversion; however, our study found no association with BMI and Tönnis grade, owing to patients with a BMI ≥35 kg/m² and Tönnis grade ≥2 being excluded to control for potential confounders.

Anterosuperior tears were the most common acetabular labral tear observed in our cohort, as well as in the broader literature.¹⁵ Superior and anterosuperior labral tears are commonly caused by forces transmitted because of the physiologic anterior orientation of the acetabulum combined with anteversion of the femur.¹⁴ Given the anatomic location of cam and pincer lesions, the superior and anterosuperior labrum is impinged with the hip in flexion, further increasing the incidence of tears in these regions.⁵ Additionally, posterior and posterosuperior tears tend to occur in the setting of forced extension and external rotation caused by trauma, which is one potential reason for the 10% incidence of these tears in our study.¹⁴

Limitations

As this is a retrospective study, there are inherent limitations with the potential for response bias, with 32.4% (166/513) of eligible patients returning completed surveys, but we attempted to minimize within-group confounding through multivariable regression models, although selection bias from differential response rates cannot be fully addressed through statistical adjustment. Another inherent limitation is that we did not have access to baseline PROMs, making it difficult to assess patient improvement. Additionally, there was a small number of patients in the posterosuperior tear cohort. Although this is expected since posterosuperior tears are relatively uncommon in the general population, the sample size limited our statistical power and ability to draw conclusions for this group, highlighting the need for further prospective studies. Studies have also shown interrater reliability for the location of acetabular labral tears to be quite low, which could limit the generalizability of this study; however, all classifications of labral tear location were performed by a single surgeon.¹⁰ Finally, all operations were done by a single surgeon within a single institution, with all patients following a specific postoperative protocol, which can also limit the generalizability of findings.

Conclusion

Acetabular labral tear location was not a significant predictor of functional or clinical outcomes after hip arthroscopy. However, while labral tear location was not predictive of conversion to THA, age and tear size were significant predictors of conversion. Overall, the location of a labral tear is not a predictor of long-term results after hip arthroscopy.

Footnotes

Acknowledgements

The authors thank the Conine Family Fund for Joint Preservation for its continued research support.

Final revision submitted January 7, 2026; accepted February 13, 2026.

The authors have declared that there are no conflicts of interest in the authorship and publication of this contribution.

Ethical approval for this study was obtained from Brigham and Women's Hospital Institutional Review Board (2011P000053).

ORCID iDs

Jackson G. Woodrow

Brandon J. Allen

Rachel L. Poutre

Rishi P. Earla

Stephen M. Gillinov

Bilal S. Siddiq

References

Adelstein

Sanghvi

Smith

, et al. Increased use of hip arthroscopy in the United States from 2015 to 2023 and projected growth through 2030. Arthroscopy. Published online March 25, 2025. doi:10.1016/j.arthro.2025.03.034

Berthelot

Brulefert

Arnolfo

Le Goff

Darrieutort-Laffite

Update on contribution of hip labral tears to hip pain: a narrative review. Joint Bone Spine. 2023;90(1):105465. doi:10.1016/j.jbspin.2022.105465

Bsat

Frei

Beaulé

PE.

The acetabular labrum: a review of its function. Bone Joint J. 2016;98-B(6):730-735. doi:10.1302/0301-620X.98B6.37099

Chahla

Nwachukwu

Beck

, et al. Influence of acetabular labral tear length on outcomes after hip arthroscopy for femoroacetabular impingement syndrome with capsular plication. Am J Sports Med. 2019;47(5):1145-1150. doi:10.1177/0363546519831291

Cho

Rhyu

Chun

Kim

MS.

Patterns of labral tears and cartilage injury are different in femoroacetabular impingement and dysplasia. J Hip Preserv Surg. 2022;9(3):151-157. doi:10.1093/jhps/hnac026

Clarke

Arora

Villar

RN.

Hip arthroscopy: complications in 1054 cases. Clin Orthop Relat Res. 2003;406(1):84

Domb

Martin

Gui

Chandrasekaran

Suarez-Ahedo

Lodhia

Predictors of clinical outcomes after hip arthroscopy: a prospective analysis of 1038 patients with 2-year follow-up. Am J Sports Med. 2018;46(6):1324-1330. doi:10.1177/0363546518763362

Domb

Sikligar

Keane

McCarroll

Kahana-Rojkind

Quesada-Jimenez

Ten-year outcomes of hip arthroscopy for the treatment of FAI and labral tears in patients with a workers’ compensation claim. J Bone Joint Surg Am. 2025;107(17):1940. doi:10.2106/JBJS.24.00996

Domb

Yuen

Ortiz-Declet

Litrenta

Perets

Chen

AW.

Arthroscopic labral base repair in the hip: 5-year minimum clinical outcomes. Am J Sports Med. 2017;45(12):2882-2890. doi:10.1177/0363546517713731

10.

Eberlin

Kucharik

Abraham

, et al. Puncture capsulotomy technique for hip arthroscopy: midterm functional outcomes. Orthop J Sports Med. 2023;11(1):23259671221144056. doi:10.1177/23259671221144056

11.

Emmons

Christoforetti

Matsuda

, et al. Arthroscopic classification of intra-articular hip pathology demonstrates at best moderate interrater reliability. Knee Surg Sports Traumatol Arthrosc. 2021;29(5):1795. doi:10.1007/s00167-202-06215-x

12.

Gan

JZW

Lie

Lee

. Clinical outcomes of meniscus repair and partial meniscectomy: does tear configuration matter? J Orthop Surg. 2020;28(1):2309499019887653. doi:10.1177/2309499019887653

13.

Gillinov

Siddiq

Cherian

Martin

SD.

Puncture capsulotomy technique during hip arthroscopy. JBJS Essent Surg Tech. 2024;14(2):e23.00061. doi:10.2106/JBJS.ST.23.00061

14.

Grant

Sala

Davidovitch

RI.

The labrum: structure, function, and injury with femoro-acetabular impingement. J Child Orthop. 2012;6(5):357-372. doi:10.1007/s11832-012-0431-1

15.

Groh

Herrera

A comprehensive review of hip labral tears. Curr Rev Musculoskelet Med. 2009;2(2):105-117. doi:10.1007/s12178-009-9052-9

16.

Harris

McCormick

Abrams

, et al. Complications and reoperations during and after hip arthroscopy: a systematic review of 92 studies and more than 6,000 patients. Arthroscopy. 2013;29(3):589-595. doi:10.1016/j.arthro.2012.11.003

17.

Haynes

Xiong

Nepple

Nunley

Clohisy

JC.

Does previous hip arthroscopy affect the clinical outcomes of total hip arthroplasty?

Orthop J Sports Med. 2019;7(3). doi:10.1177/2325967119829736

18.

Houck

Dunn

Hettrich

, et al. Estimation of location and extent of labral tear based on preoperative range of motion in patients undergoing arthroscopic stabilization for anterior shoulder instability. Arthrosc Sports Med Rehabil. 2020;2(6):e711-e721. doi:10.1016/j.asmr.2020.05.014

19.

Kokmeyer

Strzelinski

Lehecka

BJ.

Gait considerations in patients with femoroacetabular impingement. Int J Sports Phys Ther. 2014;9(6):827-838.

20.

Kuroda

Saito

Çınar

Norrish

Khanduja

Patient-related risk factors associated with less favourable outcomes following hip arthroscopy: a scoping review. Bone Joint J. 2020;102-B(7):822-831. doi:10.1302/0301-620X.102B7.BJJ-2020-0031.R1

21.

Kyin

Maldonado

Shapira

Lall

Domb

BG.

Mid- to long-term outcomes of hip arthroscopy: a systematic review. Arthroscopy. 2021;37(3):1011-1025. doi:10.1016/j.arthro.2020.10.001

22.

Levy

Kuhns

Chahal

Philippon

Kelly

Nho

SJ.

Hip arthroscopy outcomes with respect to Patient Acceptable Symptomatic State and minimal clinically important difference. Arthroscopy. 2016;32(9):1877-1886. doi:10.1016/j.arthro.2016.05.014

23.

Mayer

Fauser

Marx

, et al. Reliability of the classification of cartilage and labral injuries during hip arthroscopy. J Hip Preserv Surg. 2021;7(3):448-457. doi:10.1093/jhps/hnaa064

24.

Minkara

Westermann

Rosneck

Lynch

TS.

Systematic review and meta-analysis of outcomes after hip arthroscopy in femoroacetabular impingement. Am J Sports Med. 2019;47(2):488-500. doi:10.1177/0363546517749475

25.

Mughal

Vukanic

Murphy

Crozier-Shaw

Mahapatra

Labral tear is associated with increased risk of osteoarthritis: a cross-sectional study. J Orthop Rep. 2023;2(4):100185. doi:10.1016/j.jorep.2023.100185

26.

Naessig

Kucharik

Meek

Eberlin

Martin

Prehabilitation and rehabilitation program for patients undergoing arthroscopic acetabular labral repair: a comprehensive 5-phase patient-guided program. Orthop J Sports Med. 2022;10(2):23259671211071073. doi:10.1177/23259671211071073

27.

Nguyen

Kheyfits

Giordano

Dieudonne

Monu

JUV

. Hip anatomic variants that may mimic abnormalities at MRI: labral variants. AJR Am J Roentgenol. 2013;201(3):W394-W400. doi:10.2214/AJR.12.9860

28.

Nwachukwu

Beck

Kunze

Chahla

Rasio

Nho

SJ.

Defining the clinically meaningful outcomes for arthroscopic treatment of femoroacetabular impingement syndrome at minimum 5-year follow-up. Am J Sports Med. 2020;48(4):901-907. doi:10.1177/0363546520902736

29.

Poutre

Mun

Allen

, et al. Patients report improved functional outcomes after puncture capsulotomy technique for hip arthroscopy at 5 years. Arthroscopy. Published online May 8, 2025. doi:10.1016/j.arthro.2025.04.051

30.

Robertson

Kadrmas

Kelly

BT.

Arthroscopic management of labral tears in the hip: a systematic review. Clin Orthop Relat Res. 2007;455:88. doi:10.1097/BLO.0b013e31802c7e0f

31.

Rosinsky

Kyin

Maldonado

, et al. Determining clinically meaningful thresholds for the Nonarthritic Hip Score in patients undergoing arthroscopy for femoroacetabular impingement syndrome. Arthroscopy. 2021;37(10):3113-3121. doi:10.1016/j.arthro.2021.03.059

32.

Schairer

Nwachukwu

McCormick

Lyman

Mayman

Use of hip arthroscopy and risk of conversion to total hip arthroplasty: a population-based analysis. Arthroscopy. 2016;32(4):587-593. doi:10.1016/j.arthro.2015.10.002

33.

Tiao

Ranson

Ren

, et al. Assessment of risk factors and rate of conversion to total hip arthroplasty within 2 years after hip arthroscopy utilizing a large database of commercially insured patients in the United States. Orthop J Sports Med. 2024;12(2):23259671231217494. doi:10.1177/23259671231217494

34.

Torabian

Cherian

Dean

, et al. Outcomes of hip arthroscopy in the setting of concomitant symptomatic lumbosacral spine pathology: a matched control study with minimum 24-month follow-up. Am J Sports Med. 2023;51(12):3268-3279. doi:10.1177/03635465231197374

35.

Tresch

Dietrich

Pfirrmann

CWA

Sutter

Hip MRI: prevalence of articular cartilage defects and labral tears in asymptomatic volunteers. A comparison with a matched population of patients with femoroacetabular impingement. J Magn Reson Imaging. 2017;46(2):440-451. doi:10.1002/jmri.25565

36.

Uchida

Kizaki

Arjuna

, et al. Arthroscopic hip capsular repair improves patient-reported outcome measures and is associated with a decreased risk of revision surgery and conversion to total hip arthroplasty. Arthrosc Sports Med Rehabil. 2023;5(6):100800. doi:10.1016/j.asmr.2023.100800

37.

Ueland

Disantis

Carreira

Martin

RL.

Patient-reported outcome measures and clinically important outcome values in hip arthroscopy: a systematic review. JBJS Rev. 2021;9(1):e20.00084. doi:10.2106/JBJS.RVW.20.00084