1. science
2. medicine
3. surgery

Is It Real?
Femuro-Acetabular Impingement
FAI
• YES, since a long time ago…
– 1920 - Sir Robert Jones
– 1936 - Smith Petersen
– 1949 - Heyman
• Pistolgrip
Dr Anders Valentin
– 1975 - Stulberg
Is This FAI?
How To Define FAI?
• Symptomatic conflict between bone och ”soft tissues”
– Pain
– Reduced ROM
– Reduced function/activity level
Background to FAI/Risk Factors
• Morphology – Risk Factor
• Activity – Risk Factor
Pathology
and/or
Symptoms
• Pathology
– Labrum
– Articular Cartilage
– Synovia
– Psoas
Symptom/FAI
1
Potential Morphological Contributors
to Pathology
CAM(Femur)
CAM
Pincer
Labrum
Labral Tears
•
•
•
•
Pincer(Pelvis)
FAI
Degenerative (age)
Dysplasia (stress)
(Trauma)
Safran_JAAOS2010_vol 18_6
2
What Is Causing The Morpholgy?
• Some hereditary factors
– Anatomy/configuration
• Heavy loading/training at young age
– Remodelling of growth plates
• Fysiolysis (SCFE)
– Slipped Capital Femoral Epiphysis
– Manifest/”subclinical”
Heredity
•
•
•
•
Evolution ref bilder
Bilder olika bäcken
Ex dysplasi, profunda, retroversion
ref
Genetic Influences Are Important in the
Aetiology of Primary FAI
A TWIN STUDY
2010
T. C. B. Pollard; R. N. Villar; M. R. Norton; E. D. Fern; M. R. Williams; D. W. Murray; A. J. Carr
Remodellering av tillväxtzonen
Slipped Capital Femoral Epiphysis
3
What To Be Aware Of?
• Relatively young patients (20-40)
• Groin pain
– Position
– Activity
How To Make The Diagnosis?
1. History
2. Clinical exam
3. Imaging
X-ray/MRI/MRA/CT/3D-CT
• Reduced ROM
– Rotation/flexion
• CAM – male > female
• Pincer – female > male
What Are The Typical Symptoms?
• Pain
Clincial Findings
• Restricted ROM, flexion and internal rotation
– Position (Flexion/internal rotation)
– Activity
• Mechanical symptoms
– Catching/locking
• Reduced ROM/stiffness
• Drehmann’s sign = unavoidable passive
external rotation in deep hip flexion
• FADIR test = Impingement test
• FABER test
Pos Impingement Test
Impingement Test
Drehman’s Sign
Posterior Impingement
4
FABER Test
Imaging
• X-Ray
• CT Scan
– ”Normal” CT
– 3D reconstruction
– 3D Dynamic Simulation
• MR
– MRI
– MR-Arthrogram
– dGEMRIC (Delayed Gadolinium Enhanced MRI Cartilage)
• 3D
• Iv/ia
• (Ultrasound)
Flexion ABduction External Rotation
Normal AP Hip
Normal AP Hip
Anterior & Posterior walls of
Acetabulum
5
Ischial Spine Sign
Linear Indentation Sign
Pincer
Femoral Side
Head-Neck Offset (HNO)
MR Axial Oblique
CAM Lesion MRI Alfa angle (Nötzli)
6
What Treatment Can We Offer?
• Non-operative?
– Reduced activity level!
– Physiotherapy?
• Pelvic tilt
• Surgery
– Arthroscopic surgery
• Since > 10 years
• Nn publications
– Open surgery
• Professor Gantz – Hip preservation surgery, Bern, 1980:s
• Nn publications
Surgical Treatment
Treatment Goals?
• Reduce/eliminate symptoms
– Pain
– Mechanical symptoms
• Improve function
– Daily life
– Sports
• Better future
– Elimininate morphological risk factors
– Reduce risk for OA???
Surgery
• CAM excision
• Rim Trimming
• Labrum
– Refixation
– Resection/stabilization
– Reconstruction
• Cartilage
– Debridement, microfracture
7
CAM
Scientific Support?
•
•
•
•
•
”Before”
Numerous publications last 10 years
Increasing consistently
Limited size and F.U.
Various evaluation tools
More publications about arthroscopic FAI
surgery than open!
”After”
Examples
•
•
•
Malviya et al. (2012) Athletes and non-athletes who underwent arthroscopy for
FAI had positive results.
Byrd and Jones (2011) 2-year follow-up arthroscopy for FAI. N=100 consecutive
cases Mean age 34 years (13-76). The authors concluded arthroscopic
management of FAI has favorable outcomes.
Schilders et al. (2011) A comparative study of refixation and resection of
arthroscopic treatment of labral tears in FAI. N=151 patients with a minimum 2year follow-up . Patients without advanced degenerative changes in the hip can
achieve significant improvement in symptoms after arthroscopic treatment of
FAI.
Examples
•
•
Philippon et al. (2009) N=112 Arthroscopy for FAI. Mean 2,3-year follow-up
Arthroscopy accompanied by suitable rehab give good short-term outcomes and
high patient satisfaction.
Gedouin et al. (2010) found the results of their study confirmed the efficacy and
low associated morbidity of arthroscopy in the management of FAI. N=111. Mean
10 months follow-up, 77% of patients were satisfied or very satisfied.
8
Examples
•
•
Brunner et al. (2009) found that arthroscopic osteoplasty significantly improved
the rate and level of popular sports activities in patients with FAI. N=53. Mean
follow up 2.3 years. 45 of the 53 patients had been active in sports before the
surgery and 31 of the 45 had returned to their full accustomed level of activity at
the final follow-up.
Byrd and Jones (2009). Prospective study. N=207 hips. CAM impingement. Mean
follow-up 16 months, average age 33. 163 hips underwent correction of cam
impingement alone, and 44 hips underwent concomitant correction of pincer
impingement. Average increase of HHS was 20 points. The complication rate for
the group was 1.5%. Byrd and Jones found the short-term outcomes of the
treatment to be comparable to published reports for open methods with the
advantage of a less invasive approach.
Examples
•
•
•
Examples
•
•
•
In a 2007 study by Katz and Gomoll, they noted hip arthroscopy is permitting minimally
invasive approaches to the management of FAI. While they observed complications
occur very rarely, they did state that VIRTUALLY ALL LITERATURE ON ARTHROSCOPY
OUTCOMES COMES FROM SMALL UNCONTROLLED STUDIES WHICH MAY
COMPROMISE THE STRENGTH OF RECOMMENDATIONS REGARDING THE ROLE OF
THESE ARTHROSCOPIC SURGICAL TECHNIQUES IN CLINICAL PRACTICE.
13 patients (14 hips) with FAI secondary to pediatric hip disease were treated with hip
arthroscopy (Ilizaliturri Jr. et al. 2007). Using the WOMAC index, researchers compared
pre and post-operative mean WOMAC scores. Pre-op, the mean WOMAC score was
77.7 and post-op follow up was 87.7. Researchers noted the WOMAC index had not
been designed to evaluate hip arthroscopy. Other limitations of the study included
small patient population, short-term follow up and lack of a comparison group.
Philippon et al. (2007) retrospectively reported the outcomes of 45 professional
athletes treated with hip arthroscopy for FAI. Follow up ranged from six months to five
years with a mean of 1.6 years. Of the 45 athletes, 35 were professionally active at an
average of 1.6 years following the procedure. This study was also limited by a small
patient population and short-term follow up.
Is There Any EVIDENCE?
A 2008 systematic review by Bedi et al. found clinical literature did NOT show
open techniques to have superior outcomes to arthroscopic techniques for young,
active patients with FAI.
Larson and Giveans (2008) found arthroscopic management of patients (N=96)
with FAI resulted in significant improvement in a number of outcome measures
with good to excellent results observed in 75% of hips at a minimum 1 year
follow up. Significant improvements were seen in HHS, VAS for pain, and positive
impingement tests. 3 hips went on to total hip arthroplasty.
Guanche and Bare (2006) stated arthroscopic treatment of FAI syndrome caused
by an abnormal head-neck offset improves symptoms, restores hip morphology,
and may arrest the progression toward degenerative join disease in some patients.
They noted early results are promising. Wettstein and Dienst (2006) agreed with
these observations and also stated the early results after hip arthroscopy for
treatment of FAI syndrome are very promising.
Examples
•
156 patients (158 hips) were treated by hip arthroscopy for FAI in a preliminary
study reported on by Sampson (2005). Maximum follow up was 22 months.
Following the procedure, pain was reduced by 50% at three months, 75% at five
months and 95% at the end of the first year. Sampson’s study was limited by the
lack of comparison group and short term follow up.
Is There Strong EVIDENCE?
2010
9
2012
Evidence
What Is Negative For The Prognosis at
Surgery?
• Long symptom duration (age/degenerative
changes…)
• Reduced joint space
• Visible cartilage damage at MRÍ
• Search: 1990 - 2010: Scopus, Medline, CINAHL, Pubmed,
Ausport, SportsDiscus, PEDro, the Cochrane Library,
PsychINFO and Google Scholar.
• 4610 publications
• 29 considered OK
Connection FAI/OA?
Morphological risk factors for OA
• Is morphology a risk factor?
• Is symptomatic FAI a risk factor?
• Hur big is the risk?
– Natural history
– Post surgery
• Unchanged?
• Reduced?
• Increased?
Will ”Post-slip Deformity” Cause OA?
1933
Connection FAI/OA?
• Mechanisms are clear
• Scientific publications
• Morphologi/FAI is a risk factor!
– All CAM/Pincers don’t seem to lead to OA
Elmslie, R. C.: Remarks on aetiological factors in osteoarthritis of the hip-joint.
British Med. J. 1933; 1:1-3.
Law, W.: Osteoarthritis of the Hip. London,
Butterworth, 1952.
10
Epidemiology
”Post Slip Morphology”
2665 complete human disarticulated
skeletons from the Hamann-Todd osteological
collection at the Cleveland Museum of Natural
History that had been gathered from the unclaimed
dead at the Cleveland city morgue between 1893 and
1938.
JBJA Journal of Bone and Joint Surgery - American 1996 – 1998; October 1997, Volume 79-A, Number 10
1489 Subclinical Slipped Capital Femoral Epiphysis. Relationship to Osteoarthrosis of the Hip;
GOODMAN et al.
JBJA Journal of Bone and Joint Surgery - American 1996 – 1998; October 1997, Volume 79-A, Number 10
1489 Subclinical Slipped Capital Femoral Epiphysis. Relationship to Osteoarthrosis of the Hip;
GOODMAN et al.
JBJA Journal of Bone and Joint Surgery - American 1996 – 1998; October 1997, Volume 79-A, Number 10
1489 Subclinical Slipped Capital Femoral Epiphysis. Relationship to Osteoarthrosis of the Hip;
GOODMAN et al.
JBJA Journal of Bone and Joint Surgery - American 1996 – 1998; October 1997, Volume 79-A, Number 10
1489 Subclinical Slipped Capital Femoral Epiphysis. Relationship to Osteoarthrosis of the Hip;
GOODMAN et al.
Total
> 56YO
SCFE
38%
68%
Kontrollgrupp
26%
46%
We concluded that post-slip
deformity was a major risk factor in the
development
of severe osteoarthrosis
JBJA Journal of Bone and Joint Surgery - American 1996 – 1998; October 1997, Volume 79-A, Number 10
1489 Subclinical Slipped Capital Femoral Epiphysis. Relationship to Osteoarthrosis of the Hip;
GOODMAN et al.
11
Ant
• CAM
• Labrum tear
• Anterior Cartilage
Ant
• Pincer
• Labrum tear
• Posterior Cartilage
Hip Arthroscopy for OA?
Figure 5
MR arthrography and ia-dGEMRIC revealing severe
T1Gd changes with decreased T1Gdvalues
peripheraly and centrally in the superior aspect of
the hip.
Delayed gadolinium-enhanced magnetic
resonance imaging of hip joint cartilage: pearls
and pitfalls
Orthop Rev (Pavia). 2011 September 6;3(2):e11.
Ref
N
Anm
FU
Failure rate
Horisberger M, Brunner A, Herzog RF.
Arthroscopic treatment of femoral acetabular
impingement in patients with preoperative
generalized degenerative changes.
Arthroscopy. 2010;26:623–629.
20
NAHS
>3 år
60%
Margheritini F, Villar RN.
The efficacy of arthroscopy in the
treatment of hip osteoarthritis] [in English, Italian].
Chir Organi Nov. 1999;84:257–261.
133
HHS
18 m
36%
Walton NP, Jahromi I, Lewis PL.
Chondral degeneration and therapeutic hip
arthroscopy.
Int Orthop. 2004;28:354–356.
39
4m
72%
Christopher M. Larson MD, M. Russell Giveans
PhD, Mehul Taylor MD
Does Arthroscopic FAI Correction Improve Function
with Radiographic Arthritis?
Clin Orthop Relat Res 2011 469:1667–1676
227
(169+58)
HHS,
SF12,
VAS
>12 m
Hip Arthroscopy for FAI if OA?
• > 2 mm joint space width
• Better chance if short history/low age
• Temporary improvement/”an asymptomatic
window before the THR”
• If you find cartilage damage at surgery
– Less successful…
12
Future?
• Increasing number of surgeries (2013 - 70000 in
USA)
• Nn publications/year rapidly increasing
• Research/technical development
– Reasons/underlying mechanisms
– Profylaxis/screening/selection/warning signs
– Ex. Mayo Clinic
• Screening of morphologi (compare with scoliosis screening)
• Randomised study open/artrhoscopic surgery
Future?
• Diagnostics
– MR - dGEMRIC
– Computerized 3D dynamic analyses
• Operative technique
– Preop planning/Templates
– Technical guiding at surgery
• Rehabilitation
– Non operative treatment?
– Improved accellerated postoperative rehab
13