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Hip Update 2017 – Femoroacetabular
Impingement (FAI)
May 26, 2017
Daniel Abourbih, PGY4
Sports and Exercise Medicine Fellow – McMaster University
Emergency Medicine Resident – University of Toronto
Presentation Outline
 History Hip Impingement
 Warwick Agreement
 Consensus Questions
 Diagnostic terminology
 Clinical features
 Imaging strategies
 Treatment options
 Prevention
 Management of asymptomatic
Overview of Hip Impingement
 Concept first presented in 1936 – Sporadic mention
 Ganz et. Al 2001-2003
 Proposed link between FAI and OA
 New surgical approach for improvement of
Fem/Acetabular clearance
 365% increase in Hip Arthroscopy over a 6 year period
(1)
 Multiple Controversies
 Exact definition
 Prevention and Treatment Strategies
 Risk factor for OA development
 Health care economics concerns:
 New diagnosis
 Ambiguity of diagnostic criteria
 Costs and benefits of treatment uncertain
Warwick Agreement
 PURPOSE: International and Multidisciplinary
agreement on the diagnosis and treatment of FAI
 Open Meeting – Sports Hip Conference (June
27-28, 2016)
 Proposed questions presented and evidence
provided
 Consensus Panel of Practitioners involved in FAI
Management (June 29, 2016)
 Sports and Exercise Medicine Physicians
 Physiotherapists
 Orthopedic Surgeons
 Radiologists
 22 Clinicians/Academics, 1 patient
 9 countries
 5 specialties represented
Consensus Questions
 What is FAI Syndrome?
 How should FAI Syndrome be diagnosed?
 Appropriate Imaging Modalities?
 What is the appropriate treatment for FAI
Syndrome?
 What is the prognosis for FAI Syndrome?
 How should asymptomatic individuals with
CAM or Pincer Morphology be managed?
Agreement Meeting
 June 29, 2016
 Panel vote on each proposal
 Likert Scale 0-10
 0 – Complete Disagreement
 5 – Neither Agreement or Disagreement
 10 – Complete Agreement
 Discussions continued until:
 Mean score >7.5
 Chairman deemed no further
compromise possible
What is FAI Syndrome?
 A motion-related clinical disorder of the hip with a
triad of symptoms, clinical signs and imaging
findings
 Symptomatic premature contact between the
proximal femur and the acetabulum
 Level of agreement: mean score 9.8 (95% CI 9.6 to 10)
 KEY Feature of Definition = Must be symptomatic
 Hip Radiographic morphology without symptoms NOT
included
 Prior definitions included (2):
 Abnormal morphology of Femoral Head and
Acetabulum
 Abnormal contact between above structures
 Supraphysiological motion causing abnormal contact
 Repetitive contact causing injury
Suggested Terminology
CAM Morphology
 Bony overgrowth at Femoral
Head/Neck Junction
 Results in Non-spherical CAM shaped
morphology
 CAM impingement – FemoroAcetabular contact in Flexion/Internal
Rotation
 Associated with Antero-Superior Labral
and Chondral Damage
 Described by Alpha Angle
 Quantifies the extent to which the
femoral head deviates from spherical
 Normal <55-60 deg
 Other: Pistol Grip Deformity
 Found in 15-25% of Population
Pincer
Morphology
 Pathological contact between the acetabular labrum and rim and the femoral head-neck
junction – Essentially Acetabular Overcoverage
 Labral Injury, Less Chondral Injury
 May result in Labral Ossification worsening overcoverage
 Associated with:
 Acetabular Retroversion
 Coxa Profunda
 Protrusio Acetabuli
How should FAI be diagnosed?
 Symptoms, clinical signs, and imaging findings must be
present
 Level of agreement 9.8/10 (95% CI 9.6-10)
 Primary Symptoms of FAI
 Motion-related Hip/Buttock pain – “C-sign”
 Pain can also be felt in back, thigh, and knee
 Mechanical symptoms – Clicking, catching, locking,
stiffness, giving way
 Presenting Symptoms Vary
 Some experience with Vigorous Activity – Ex. Football
 Onset with supraphysiologic motion – Ex. Dance,
Gymnastics
 Present at rest – Ex. Prolonged sitting
Clinical Signs required?
 Diagnosis does not depend on single clinical sign
 Significant heterogeneity in performance and interpretation
of PE maneuvers
 Studied in populations with high Pre-test Probability
 Hip Impingement test generally reproduce patient’s
symptomatology (3)
 FADIR – Sensitive but not specific (High False Positive Rate)
 Sensitivty 94-99%
 Specificity 9-23%
 Typically restricted internal rotation
 Suggested Physical Exam should include:
 Gait, single leg control
 Muscle tenderness around hip
 Hip ROM – Internal and External rotation
 Special tests – FABER, FADIR, Log Roll
Role of Image-guided injection in Diagnosis?
 Multiple potential soft-tissue confounders to diagnosis
 Lumbosacral spine, Iliopsoas/Adductor Strains, GT Bursae, Gluteal Ensethopathy, Piriformis Syndrome
 Authors do advocate the use to Image-guided IA local anesthetic injections – Fluro or U/S
guided (4)
 Has been shown to differentiate intra-articular from Extra-articular pathologies
Imaging for FAI Syndrome?
 AP Pelvis and Lateral Femoral Neck View
 AP pelvis – Centered on Pubic Symphysis, Limit rotation and pelvic tilt
 Lateral view – Cross-table lateral, Dunn and frog lateral
 CAM – Flattening or convexity at the Femoral Head/Neck junction
 Pincer – Global or focal femoral head over coverage by the acetabulum
Advanced Imaging?
 Limitations of Plain Radiographs
 Low sensitivity for morphology detection
 Ex. CAM alpha angles – Poor sensitivity
discriminating Symptomatic and
Assymptomatic (6)
 Recommend Cross-sectional Imaging
 Further assessment of morphology, 3D
reconstruction
 MRI Arthrogram suggested - Associated
cartilage or labral injury
 Assessment of other possible Hip/Groin soft
tissue causes of pain
 Always correlate with clinical symptoms
 Assymptomatic Labral Tears
 Assymptomatic CAM/Pincer Morphologies
Treatment for FAI Syndrome?
 Can be treated by Conservative care,
Rehabilitation, or Surgery
 Conservative treatment – Education, Watchful
waiting, or lifestyle and activity modification
 Rehabilitation – Improve hip stability,
neuromuscular control, strength, ROM, and
movement patterns
 Surgery – Open or arthroscopic, repair soft-tissue
damage and correct FAI morphology
 Level of agreement: mean score 9.5 (95% CI 9.0 to
10)
 Emphasized Shared decision options – Practically, a
trial of conservative and rehabilitation prior to
surgical options
Rehabilitation Protocol?
 Heterogenous Interventions
suggested
 Taping/Positioning
 Gluteal/Abdominal strengthening
 Hip flexor strengthening
 Core strengthening
 No High Quality RCT data
available
 GRADE Quality of Evidence: Low
to Very Low
Hip Arthroscopy
 Primary Surgical corrective technique
 Treatment of Labral and Chondral injuries in
the central compartment by traction
 Allows Femoral/Acetabular bony correction
 Inadequate/Inappropriate bone correction –
Most common cause of treatment failure
 Overcorrection – Risk of Femoral Neck #, Loss
of Hip fluid seal
 Overall complication rates low (<4%)
 Lat Fem Cutaneous nerve
 Pudendal nerve
 Iatrogenic labral/chondral damage
Open vs. Surgical Correction of CAM Deformity
Open Surgical
Hip Dislocation?
 May be more ideal treatment for severe/complex FAI Deformities
 CAM Lesions with Posterior Extension
 Severe Global Acetabular Overcoverage
 Extra-articular impingement
 Relatively low rates of complication
 Trochanteric Non-union 1.8%
 Longer recovery times documented
Surgical Outcomes?
 Casartelli NC, et al. Br J Sports Med 2015;49:819–
824
 Systematic review of 1076 Hips
 Equal distribution of M:F, High level to Recreational
Athletes
 73% Arthroscopic, 21% Open Approach
 Femoral Osteoplasty 90%, Acetabular Rim
Trimming 51%
 Labral Tear Treatment
 38% repaired
 35% debrided
 6% Partialy resected
 Acetabular and Femoral Cartilage treatment
 Rehabilitation Protocols
 Level IV – Low level Evidence (Case Series)
Rate of Return to Sport = 87% (56100%)
Rate of Return to SAME level = 82%
(55-100)
Prognosis for FAI?
 Cam morphology is associated with hip
osteoarthritis.
 OR range from 2.2-20
 OA risk may depend on degree
Moderate Alpha >60 deg – OR 2.5
Severe Alpha > 83 deg – OR 9
 Pincer Morphology less closely related
 It is currently unknown whether treatment for FAI
syndrome prevents hip osteoarthritis.
 Level of agreement: mean score 9.6 (95% CI 9.3
to 9.8).
Asymptomatic CAM/Pincer Morphology
 Environmental Causes
 Suggested 2nd to excessive Hip Loading
 89% Prevalence in Skeletal Mature Bball
 50% in Symptomatic Soccer Players
 Only 9% found in cohort of pre-pubescent
males
 ?Physeal Damage or Physiological Adaptation
to Stress
 Should we limit/alter the activity of
Adolescents demonstrating CAM morphology?
Asymptomatic CAM/Pincer Morphology
 Many patient with radiographic
evidence WON’T develop OA
 PPV = 6-25%
 NPV = 98-99%
 Other Factors at play
 Level of activity
 Degree of impingement
 Obesity/Trauma/Classical OA risk factors
 Current Recommendations
 No role for Preventative Surgery
 Preventative Physio-Led rehabilitation
suggested
Summery of Recommendations
 FAI Syndrome is clinical triad of symptoms, signs, and
radiographic features
 Xrays/Crossectional Imaging and Image-guided injections
are a key component in diagnosis
 Lifestyle modification, Physiotherapy, and other conservative
measures form the backbone of basic treatment
 Arthroscopic repair has supplanted open techniques for
most repairs
 CAM morphology associated with OA but unable to predict
which individuals are truly at risk
Future Directions
References
 Montgomery SR, Ngo SS, Hobson T, et al. Trends and demographics in hip arthroscopy in the
United States. Arthroscopy 2013;29:661–5
 Sankar WN, Nevitt M, Parvizi J, et al. Femoroacetabular impingement: defining the condition
and its role in the pathophysiology of osteoarthritis. J Am Acad Orthop Surg 2013;21(Suppl
1):S7–S15
 Kivlan BR, Martin RL, Sekiya JK. Response to diagnostic injection in patients with
femoroacetabular impingement, labral tears, chondral lesions, and extra-articular
pathology. Arthroscopy 2011;27:619–27
 Reiman MP, Goode AP, Cook CE, et al. Diagnostic accuracy of clinical tests for the diagnosis
of hip femoroacetabular impingement/labral tear: a systematic review with meta-analysis. Br
J Sports Med 2015;49:811.
 Sutter R, Dietrich TJ, Zingg PO, et al. How useful is the alpha angle for discriminating between
symptomatic patients with cam-type femoroacetabular impingement and asymptomatic
volunteers? Radiology 2012;264:514–21.
 Wall PD, Fernandez M, Griffin DR, et al. Nonoperative treatment for femoroacetabular
impingement: a systematic review of the literature. PM R 2013;5:418–26.