Diagnosis and Management of Femoroacetabular Impingement (FAI)

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Diagnosis and Management of Femoroacetabular
Impingement (FAI)

• Jason W. Folk, MD
• Steadman Hawkins Clinic of the Carolinas
• February 2012

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Disclosures

• Consultant Smith Nephew Endoscopy

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Femoroacetabular ImpingementOutline

• Background
• Pincer and Cam lesions
• Physical Exam findings
• Imaging
• Open vs Arthroscopic tx

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Femoroacetabular Impingement

• Abnormal dynamic contact between proximal femur
  and acetabulum that results in damage to femoral
  neck, acetabular rim, hip labrum, and articular
  cartilage.

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• in certain aberrant morphologic features of the
  hip, abnormal contact between the proximal femur
  and the acetabular rim that occurs during
  terminal motion of the hip, leads to lesions of
  the acetabular labrum and/or the adjacent
  acetabular cartilage.

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Femoroacetabular Impingement

• Why do we talk about the labrum so much?
• The first recognized pathologic consequence to
  deformity
• Multiple biomechanical functions
• Injury to labrum now recognized as a marker of
  significant underlying pathology

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• Labral Function
• Seals pressurized fluid layer within joint
• Lubricates, prevents direct cartilage contact
• Slows rate of fluid expression from porous
  cartilage layers
• Limits cartilage deformation and stress

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• Labral Function
• Provides mechanical stability
• Substantial extension of acetabular rim
• Contributes to load transmission

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Adult Hip Osteoarthritis

• Up to 90 of Young patients that develop DJD of
  the Hip Have an underlying structural Problem

Ganz et al, CORR 2008
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Adult Hip Osteoarthritis

• Theory was Postulated over 40 years ago
• Murray 1965
• Solomon et al 1973
• Harris 1983
• Mechanism was Missing
• Ganz, Leunig et al. 1996

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Progression of Hip DiseaseFAI
1986
28 yo
Pistol Grip deformity Stulberg SD 1975
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Progression of Hip DiseaseFAI
1994
1986
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Progression of Hip DiseaseFAI
1994
2007
47 yo
1986
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Prevalence of FAI 10-15Anterior hip pain
(C-sign)Pain Protracted sitting With
ambulation catching arising from
seatDifficulty In and out of car Don/doff
shoes and socks

• Hip Pain
• Patient Assessment

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Physical Exam
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Clinical tests
Posterior Impingement
Anterior impingement
Leunig M et al. Operat Tech Orthop, 15247, 2005.
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Clinical tests
The impingement test is performed with the hip in
90 of flexion with additional internal rotation
and adduction of the femur.
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Two Types Pincer and Cam

• Classification

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Pincer Type
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Pincer Type

• Impingement caused by retroversion of the
  acetabulum
• Primarily labral pathology
• Secondarily develop articular breakdown
• MF 13
• Avg age 40 (40-57)

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contre-coup
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contre-coup
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• Imaging
• Physiologic Anteversion

Anterior Wall
Posterior Wall
1/2
1/3
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• Imaging
• Acetabular Retroversion

Cross over sign
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• Retroverted Acetabulum/
• Crossover Sign

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Retroversion
CT axial cuts normal anteversion
retroverted
Reynolds D J Bone Joint Surg 81-B 281-288 1999.
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Cam type
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Cam type

• Impingement from bony prominence of anterolateral
  femoral head/neck junction
• Selective articular delamination (relative labral
  preservation)
• MF 141
• Avg age 32 (21-51)

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Cartilage labral delamination
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Imaging
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Cam FAI-aspherical femoral head decreased
head-neck offset

• Alpha Angle
• Head-Neck Offset
• Loss of Sphericity

HD
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Surgical thinking Restore the Anatomy of the hip
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Restoring Anatomy

1. Functionality of Labrum
2. Sphericity of Femoral Head
3. Normal Acetabular Version

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PINCER Impingement
Hip arthroscopy Conservative 20 yrs.,
college track runner
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PINCER Impingement
20 yrs., college track runner hip
arthroscopy
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CAM Impingement
Hip arthroscopy
Femoral Osteoplasty
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CAM Impingement
Hip arthroscopy
Femoral Osteoplasty
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Thank You