Biomechanical Comparison of Native Acetabular Labrum,Fresh-Frozen Meniscus,and Fresh-Frozen Anterior Tibialis Tendon for Labral Reconstruction

Abstract

Background:

Acetabular labral tears can lead to hip pain and dysfunction and progress to osteoarthritis if left untreated. While surgical repair is the gold standard, reconstruction with grafts is necessary in cases of irreparable labral damage. Clinical data suggest that meniscal allografts may offer superior outcomes as compared with anterior tibialis tendon allografts, but biomechanical comparisons remain limited.

Hypothesis/Purpose:

This study aimed to compare the tissue properties of the native acetabular labrum, fresh-frozen medial meniscal allograft, and fresh-frozen anterior tibialis tendon allograft. The null hypothesis was that the fresh-frozen medial meniscus will not have statistically different biomechanical properties to the native labrum and fresh-frozen anterior tibialis tendon.

Study Design:

Controlled laboratory study.

Methods:

Samples of the native labrum (n = 6), fresh-frozen meniscus (n = 6), and fresh-frozen anterior tibialis tendon (n = 6) were standardized and biomechanically tested using a 3-phase protocol on an Instron materials testing machine. Properties measured included ultimate strength, yield force, yield strength, stiffness, Young modulus, and work to failure. One-way analysis of variance with post hoc Tukey was performed to determine statistically significant differences among tissue types. Significance was set at P < .05.

Results:

Ultimate strength, yield force, and Young modulus were not significantly different across tissue types. Native labrum exhibited significantly higher yield strength (mean ± SD; 48.25 ± 14.56 MPa) when compared with the meniscus (26.69 ± 6.51 MPa) and anterior tibialis tendon (27.50 ± 5.02 MPa; P = .002). Stiffness was greater in the anterior tibialis tendon (159.35 ± 44.11 N/mm) than in the native labrum (89.07 ± 26.76 N/mm) and meniscus (112.84 ± 56.74 N/mm; P = .027). Work to failure was highest in the native labrum (1143.62 ± 551.31 N·mm) versus the meniscus (310.44 ± 168.29 N·mm) and tibialis tendon (265.93 ± 131.48 N·mm; P = .001).

Conclusion:

Clinical Relevance:

These findings support the use of medial meniscal allograft in acetabular labral reconstruction given its biomechanical similarity to native labral tissue, reinforcing prior clinical data and aiding graft selection in hip preservation surgery.

Keywords

labral tear meniscal allograft labral reconstruction hip preservation

The number of patients undergoing operative management of acetabular labral pathologies, such as labral tears, has increased in recent years.³¹ Hip labral tears can be associated with femoroacetabular impingement in young adults.^12,17 Labral tears refractory to nonoperative management can lead to persistent pain and functional limitations, development of hip osteoarthritis, and the need for total hip arthroplasty.^15,19,25 Patients with labral tears whose nonoperative management fails benefit from surgery, which may prevent the more adverse complications of these tears. The gold standard treatment for acetabular labral tears has been open or arthroscopic repair and correction of underlying impingement or other causes of nonarthritic hip pain. In instances where there is irreparable damage to the labrum, labral reconstruction can be performed to preserve the fluid seal between the acetabulum and femoral head.^21,24 Autograft and allograft options exist for acetabular labral reconstruction: for autografts, ligamentum teres capitalis, iliotibial band, gracilis, quadriceps tendon, capsular, and indirect head of the rectus femoris; for allografts, semitendinosus, peroneus brevis tendon, tensor fascia lata, posterior tibialis, and anterior tibialis.^§

The goal of labral reconstruction is to re-create the native mechanics of the hip joint as much as possible. Meniscal allograft may be a good proxy for the native labrum, owing to similarities in tissue composition, morphology, architecture, and metabolic profiles as compared with the acetabular labrum.^3,13,28 Cook et al⁶ compared outcomes between patients undergoing labral reconstruction with fresh-frozen anterior tibialis allografts and those with fresh meniscal allografts. They found that the outcomes for patients undergoing fresh meniscal allograft labral reconstruction—namely, visual analog scale for pain, Hip Disability and Osteoarthritis Outcome Score for Joint Replacement, and Patient-Reported Outcomes Measurement Information System Physical Function—were not significantly different from those of patients undergoing labral reconstruction with fresh-frozen anterior tibialis allograft. Furthermore, the postoperative magnetic resonance imaging findings were subjectively better in the meniscal allograft group. These findings suggest that fresh meniscal allograft may be an acceptable choice as compared with fresh-frozen anterior tibialis allograft in the clinical setting.

In the clinical setting, fresh meniscal allograft is superior to fresh-frozen meniscal allograft; however, when tested biomechanically, circumferential-peripheral fresh and fresh-frozen meniscal allografts were similar in failure strain and tensile modulus.³⁰ Therefore, the combination of similar biomechanical results, lower costs, and greater tissue availability makes fresh-frozen meniscal allograft an acceptable tissue choice to compare with fresh-frozen anterior tibialis tendon allograft and native labral tissue.^5,16

Although prior clinical studies have compared various graft types, limited data exist regarding the biomechanical properties of the native acetabular labrum, fresh-frozen medial meniscal allograft, and fresh-frozen anterior tibialis tendon. As such, the objective of the current study was to characterize and compare the mechanical properties of these tissues. The null hypothesis was that the medial meniscus would not exhibit statistically different biomechanical properties as compared with the native labrum or anterior tibialis tendon. All tissues were tested in tension to define their material properties; however, because the acetabular labrum is not physiologically loaded in pure tension, these results primarily reflect baseline mechanical characteristics rather than true in vivo hip biomechanics, which have been evaluated separately in a cadaveric model.⁷

Methods

Tissue Preparation

Tissues were acquired as follows: fresh-frozen medial menisci (n = 6; 4 male, 2 female; mean age, 37.4 years), fresh-frozen tibialis anterior tendon (n = 6; 5 male, 1 female; mean age, 42.8 years), and native acetabular labrum (n = 6; 5 male, 1 female; mean age, 41.1 years; mean body mass index, 28.5). Native acetabular labral tissues were acquired from cadaveric specimens (ScienceCare). Fresh-frozen anterior tibialis tendon and medial meniscus were obtained from otherwise discarded portions of allografts (Musculoskeletal Transplant Foundation Biologics and Arthrex, Inc). Tissue from the medial meniscus was taken from the middle horn. Acetabular labral tissue samples were collected from the 12- to 3-o’clock position on the acetabulum.

All tissue samples were cut and standardized to a length of 20 mm and width of 5 mm. A 5-mm segment from the leading edge of the medial meniscus was measured and harvested. Tendon tissue used in the current study was obtained from a 20-mm segment of the distal end of the anterior tibialis. These length and width measurements were selected to adequately clamp to the biomechanical testing construct. Tissue height varied owing to different locations and functions of tissue. Once the tissue was cut to the aforementioned dimensions, it was stored in phosphate-buffered saline at room temperature (20°C-22°C) for at least 24 hours until it was able to be biomechanically tested.

Biomechanical Testing

Tissue samples were secured to a materials testing machine (Instron Corp) using 2 Instron 2710-144 Screw Slide-Action Grips (Figure 1). Serrated clamps held tissue samples in place during testing to avoid tissue slippage. Samples were secured to the materials testing machine and underwent a 3-phase testing protocol: preloading, preconditioning, and testing.

This novel testing protocol was based on industry standards.^4,10 Preloading consisted of a 1-N linear distraction force to remove any laxity in the tissue. Next, samples were preconditioned to be stretched to 2% strain cyclically for 10 cycles. Each cycle lasted for a 2-second period: 1 second for ramp-up and 1 second for ramp-down. The testing protocol consisted of samples being held at 2% strain for 100 seconds; then, samples were loaded to failure at a linear rate of 3 mm/s. The biomechanical testing protocol is novel and was designed by an experienced biomedical engineer. Ultimate strength, yield force, yield strain, stiffness, Young modulus, and work to failure were all measured for each tissue sample. Data were stored, recorded, and analyzed (Figure 2).

Statistical Analysis

Descriptive statistics were calculated to report mean and standard deviation for each measured variable. One-way analysis of variance with post hoc Tukey was performed to determine statistically significant differences among tissue types. Significance was set at P < .05.

Results

All specimens underwent the full biomechanical testing protocol.

Ultimate Strength

Ultimate strength, which is the maximum force that a tissue can withstand before failing under tension, was measured in megapascals. Ultimate strength was not significantly different among the native labrum (mean ± SD; 38.38 ± 10.23), frozen medial meniscus (12.69 ± 5.93), and frozen anterior tibialis tendon (10.09 ± 2.96; P = .07) (Table 1, Figure 3).

Table 1

Biomechanical Testing of the Native Labrum, Fresh-Frozen Meniscus, and Fresh-Frozen Anterior Tibialis Tendon

	Labrum		Meniscus		Anterior Tibialis Tendon
	Mean	SD	Mean	SD	Mean	SD	P Value ^a
Ultimate strength, MPa	38.38	10.23	12.69	5.93	10.09	2.96	.07
Yield force, N	345.04	100.81	218.93	113.05	274.51	85.57	.13
Yield strength, %	48.25	14.56	26.69	6.51	27.50	5.02	.002
Stiffness, N/mm	89.07	26.76	112.84	56.74	159.35	44.11	.027
Young modulus, Mpa	89.49	26.87	62.35	33.21	59.75	11.91	.12
Work to failure, N·mm	1143.62	551.31	310.44	168.29	365.93	131.48	.001

Bold indicates P < .05.

Yield Force

Yield force, which is the amount of force that a tissue can withstand before permanent deformation, was measured in newtons. Yield force was not significantly different among the native labrum (345.04 ± 100.81), frozen medial meniscus (218.93 ± 113.05), and frozen anterior tibialis tendon (274.51 ± 85.57; P = .13) (Figure 4).

Yield Strength

Yield strength, as measured in megapascals, is the ultimate strength level at which point the tissue begins to fail under a longitudinal load. Yield strength was significantly different among the native labrum (48.25 ± 14.56), frozen medial meniscus (26.69 ± 6.51), and frozen anterior tibialis tendon (27.50 ± 5.02; P = .002). Post hoc analysis revealed that the native labrum experienced higher yield strain than the frozen anterior tibialis tendon and frozen medial meniscus (Figure 5).

Stiffness

Stiffness, which is a tissue's resistance to deformation under stress, was measured by dividing force by displacement in newtons per millimeter. Stiffness was significantly different among the native labrum (89.07 ± 26.76), frozen medial meniscus (112.84 ± 56.74), and frozen anterior tibialis tendon (159.35 ± 44.11; P = .027). Post hoc analysis revealed that the frozen anterior tibialis tendon was able to resist greater force than the native labrum and frozen medial meniscus (Figure 6).

Young Modulus

Young modulus, which is a measure of a tissue's elasticity, was measured in megapascals. Young modulus was not significantly different among the native labrum (89.49 ± 26.87), frozen medial meniscus (62.35 ± 33.21), and frozen anterior tibialis tendon (59.75 ± 11.91; P = .12) (Figure 7).

Work to Failure

Work to failure, which is the total amount of energy absorbed by the tissue before it fails, was measured in newton millimeters. Work to failure was significantly different among the native labrum (1143.62 ± 551.31), frozen medial meniscus (310.44 ± 168.29), and frozen anterior tibialis tendon (265.93 ± 131.48; P = .001). Post hoc analysis revealed that native labrum was able to absorb a greater amount of energy before failure as compared with the frozen medial meniscus and frozen anterior tibialis tendon (Figure 8).

Discussion

This study demonstrates that the medial meniscus and anterior tibialis tendon share biomechanical properties and are different when compared with the native labrum. Yield strength and work to failure were significantly greater for the labrum, while stiffness was significantly greater for the anterior tibialis tendon, allowing for the rejection of the null hypothesis. These findings indicate that the medial meniscus exhibits stiffness more closely aligned with the anterior tibialis tendon than with the native labrum. Collectively, these results support the use of medial meniscal allografts for acetabular labral reconstruction, given the tissues’ biomechanical similarity to the anterior tibialis tendon.

Stiffness, which is the resistance to longitudinal load, was higher in the anterior tibialis tissue group than the labral and medial meniscal groups. This is likely due to the native function of the 3 tissue groups. The anterior tibialis tendon must resist tension created by muscular forces during dorsiflexion and during the first phase of gait.¹⁴ Conversely, the labrum and medial meniscus function to resist compression and hoop stresses to create joint stability and protect underlying articular cartilage. Within the femoroacetabular joint, stiffer tissue likely means a decreased ability to act as a shock absorber and to marginally deform to maintain a synovial suction seal.²

Yield strength, which is the percentage of the tissue's ultimate strength at the point where the tissue begins to fail under a longitudinal load, was significantly higher in the labral tissue group as compared with the medial meniscal and anterior tibialis group. Work to failure, which is the amount of work needed to reach failure under a longitudinal load, was also significantly higher in the labral tissue group as compared with the other tissue groups. While there are differences in biomechanical tissue properties among the 3 tissue types, it is unlikely that tissues in the setting of an acetabular labral reconstruction will experience a high longitudinal distraction force like the ones experienced in the current study. The tissues in the setting of an acetabular labral reconstruction will experience compressive forces between the acetabulum and the femoral head and facilitate joint stability. The purpose of the current study was to assess the tensile material properties of the different tissue options and compare their properties against native labral tissue, not on the effect on femoracetabular joint stability.

To our knowledge, this study is the first to compare tissue properties among the medial meniscus, anterior tibialis tendon, and native labrum. Ferro et al¹¹ previously compared the acetabular labrum, iliotibial band, semitendinosus, gracilis, and anterior tibialis by cyclically elongating tissues. The biomechanical study found that all tested grafts and the acetabular labrum exhibited similar cyclic elongation behavior in response to simulated physiologic forces. However, while cyclic elongation is a key factor in determining the functional integrity of graft tissues under repetitive loading conditions, such as walking or running, it does not fully encapsulate the biomechanical properties relevant to labral reconstruction.

This study expands on previous work by incorporating multiple biomechanical parameters that include ultimate strength, yield force, stiffness, Young modulus, and work to failure. These additional metrics provide a more comprehensive understanding of how different graft options compare with native labral tissue under tensile loading conditions. Given that the medial meniscus demonstrated ultimate strength, yield force, yield strength, Young modulus, and work-to-failure values comparable to the anterior tibialis tendon, our findings suggest that it may be a suitable graft option for labral reconstruction.

Furthermore, the results highlight important functional distinctions between graft options. The increased stiffness observed in the anterior tibialis tendon suggests that it may be less capable of mimicking the labrum's role in accommodating joint movement and distributing loads across the femoroacetabular joint. The native acetabular labrum demonstrated higher yield strength and work to failure as compared with the medial meniscus and anterior tibialis tendon, likely because of its specialized collagen fiber orientation and fibrocartilaginous composition optimized for the multidirectional loading of the hip joint. In contrast, the medial meniscus and anterior tibialis tendon are adapted for compressive and tensile forces, respectively, rather than the shear and hoop stresses typical of the femoroacetabular joint. Although both grafts exhibited lower mechanical properties, the forces encountered during normal hip function are unlikely to exceed their elastic limits, suggesting that they remain mechanically sufficient for labral reconstruction.

Limitations

There are several limitations that we acknowledge with this study. First, 4 serrated clamps held tissues during biomechanical testing. There is a possibility that tissues could have slipped during testing. Because all tissues and tissue types were tested by the same methodology, any error attributed to slippage would be present among all tissues and tissue types, limiting a potential confounding factor. Another limitation to this study is that biomechanical testing occurred outside of the tissue's natural environment. Care was taken to minimize tissue time outside of the phosphate-buffered saline solution to keep tissues adequately hydrated, but this was unlikely to mimic the true in vivo environment of the acetabular labrum. The entire meniscus was not used in this biomechanical test; rather, 5-mm uniform sections were used. The current study was performed to mimic timepoint zero, which may not reflect the tissue properties in the in vivo setting. As this was a materials testing comparison study, biomechanical tests specific to the evaluation of the femoracetabular joint were not performed. The current study was performed with native labral tissue and 2 graft options, and there are many other options available for use in labral reconstructions. Finally, this study used fresh-frozen medial meniscal tissue rather than fresh medial meniscal tissue, which has been proven to have superior clinical outcomes, as previous biomechanical testing reported similar tissue properties between fresh and fresh-frozen medial meniscus.⁶ Fresh-frozen medial meniscus was also chosen for greater availability and lower cost as compared with fresh medial meniscus.

Conclusion

The stiffness of the medial meniscus tested closer to the native labrum than the anterior tibialis, but both grafts had significantly lower yield strength and work to failure than the native labrum. Together, the results indicate that the medial meniscus and anterior tibialis are viable graft options, but they do not replicate the tissue properties of the native labrum. Further biomechanical testing mimicking hip flexion, extension, adduction, and abduction are needed to better evaluate the performance of various tissues in the setting of an acetabular labral reconstruction and the effect on femoracetabular joint stability. These studies are ongoing at our institution.

Footnotes

Final revision submitted January 20, 2026; accepted January 27, 2026.

One or more of the authors has declared the following potential conflict of interest or source of funding: B.D.C. is a board or committee member for AO Trauma North America, Fragility Fracture Network USA, International Geriatric Fracture Society, and Orthopaedic Trauma Association; has received financial or material support from Arthrex, Inc; has received consulting fees from Curvafix, KCI, and Synthes; has received royalties from Globus Medical; has received research support from Synthes; is a paid presenter or speaker forDePuy; is on the editorial or governing board for Journal of Hip Preservation, Journal of Orthopaedic Trauma, and SLACK Incorporated; is an unpaid consultant for Osteocentric and Urgo Medical; and holds stock or stock options in RomTech. J.L.C. has received research support from Arthroscopy Association of North America, AAOS, AO Trauma, Advanced Research Projects Agency for Health, Arthrex Inc, Gallant, National Institutes of Health, OrthoBio Therapeutic, Orthopaedic Research and Education Foundation, and Patient-Centered Outcomes Research Institute; consulting fees from Trupanion and Arthrex Inc; and royalties from Arthrex and Thieme; and is on the editorial board for Journal of Knee Surgery; is a board or committee member for Midwest Transplant Network; and is a board or committee member and receives intellectual property royalties research support from Musculoskeletal Transplant Foundation/MTF Biologics. S.F.D. has received research support from Arthrex, Orthopaedic Research and Education Foundation, and Stryker Corp; consulting fees from Stryker Corp; and publishing royalties and financial or material support from Elsevier; is a board or committee member for American Orthopaedic Society for Sports Medicine and Arthroscopy Association of North America; is on the editorial board for Arthroscopy; and is a paid presenter or speaker for AO North America.

ORCID iDs

Ashwin R. Garlapaty

Steven F. DeFroda

Notes

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