Femoroacetabular Impingement

CharlesJ.Gatt,Jr.,MDChair,DepartmentofOrthopaedicSurgery

RutgersRobertWoodJohnsonMedicalSchoolNewBrunswick,NJ

• NoDisclosures

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Questions

• Whatisfemoroacetabularimpingement?• WhatarethetreatmentoptionsforFAI?• CanarthroscopichipsurgeryalterthenaturalhistoryofFAI?

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Femoroacetabular impingementFAI

• Abnormalcontactbetweenacetabulumandfemoralhead-neckjunction

• Recurrentimpingingleadstoacetabularlabraltearingandadjacentcartilagedamage

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CAM Impingement

• Femoralbaseddisorder» Decreasedhead-to-neckratio» Asphericalfemoralhead» Decreasedfemoraloffset» Femoralneckretroversion» PriorSCFEdeformity

• Usuallyinyoung,athleticmales

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Pincer Impingement

• Acetabularbaseddisorder» Anterosuperior rimoverhang» Acetabularretroversion» Acetabularprotrusio» Coxaprofunda

• Usuallyinactive,middle-agedwomen

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History

• Symptoms» Activityrelatedgroinorhippain» Exacerbatedbyhipflexion» Difficultysitting» Mechanicalhipsymptoms» Glutealortrochantericpain

» duetoaberrantgaitmechanics

» Csign

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Physical examination

• Symptoms» Limitedhipflexion(<90°),

especiallywithinternalrotation(<5°)

» Anteriorimpingementtest(flexion,adduction,internalrotation)

» Externallyrotatedextremity

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Radiographic evaluation

• APPelvis» AssessforPincerlesion» Crossoversign» Acetabulardysplasia

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Radiographic evaluation

• Lateralview» Assessforcamlesion» Extendedfemoralnecklateral» Dunnview

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Alpha angle

• Alphaangle» >55° →CAM

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MRI arthrogram

• Bettervisualizationoflabrum• Intraarticular cortisoneinjection

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Role of the labrum• Roleinloadtransmission(Konrath,JBJS’98)

» Removaldidnotchangecontactarea,load,meanpressure,ormaximumpressureinanteriororsuperioracetabulum

» Decreaseinmaximumpressureandmeanpressureinposterioracetabulum

• Systematicreview(Zaltz,CORR’12)» Lowlevel,conflictingdataonroutinerepairs» Someevidencetoreattachinconjunctionwithrimtrimming

• Refixation >debridement(Krych,Arthroscopy’13)» Significantlygreaterimprovementsin“repair”group

» majoritycombinedlesionsneedingpincerresection

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Epidemiology• AsymptomaticCAMin14%generalpopulation(Hack,JBJS’10)

» 17%prevalenceinadolescents(Li,JPO’17)

• Increasedprevalenceincompetitiveathletes» NFLcombine(Nepple,Arthroscopy’12)

» 94%patientswithhx hiporgroinpainhadradiographicFAI» 62%combined,10%CAM,23%pincer» 72%acetabularretroversion

» Eliteicehockeyplayers(Lerebours,AJSM’16)» 17%hx hippain+radiographicCAM» 70%hipshadCAM

» only8%ofthesepatientshad+impingementtests» Majorityasymptomatic

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Epidemiology – youth sports• Hockey“atrisk”positioning(Stull,AJSM’11)» Impingementduringsprintstart

• Adolescenthockeyplayers(Philippon,AJSM’13)» Higherα-anglesthanskiers

» 4.5xmorelikelytohaveanα-angle>55°» Positivecorrelationbetweenageandα-angle

• Deformityformation(Agricola,AJSM’14)» IncreaseinradiographicCAMover2yearsfor12-13y/omale

soccerplayers» Noincreaseafterproximalfemoralphysis closure

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Osteoarthritis• Acetabulardamage(Beck,JBJS’05)» CAM→shear→separationcartilagefromlabrum» Pincer→compression→labraldegeneration+posterior

• End-stageOA(Nicholls,ArthritisRheum’11)» RadiographicCAMpredictsTHAat19years» 1° increaseinα-angleincreasesTHAriskby6%

• Causality(Agricola,AnnRheumDis’13)» SevereCAMdeformityandlimitedIRpredisposetorapid

end-stageOA+THA

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Labral debridement and femoroplasty

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Rim trimming and labral reattachment

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Outcomes• Age&gender(Frank,JBJS’16)

» Allpatientsexperiencedsignificantimprovements» Olderpatients(age>45years)hadlessimprovement

» Femalepatients>45y/obenefitedtheleast

• Adolescent&youngpatients(Cvetanovich,JPO’16)» Allexperiencedstatisticallysignificantimprovements

» >80%clinicallysignificant

• Systematicreview&meta-analysis(Minkara,AJSM’18)» 5.5%reoperationrisk(revisionorTHA)» 1.7%complications(HO,transientLFCNneuropraxia)» Averageα-angledecrease24°» Advancedarthritisleadtopooreroutcomes

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Outcomes – athletes• Returntosport(Weber,Arthroscopy’17)» High-levelandrecreationalathletesboth90%ratereturn» Longerreturntimeifout>8months

• NHL(Menge,AJSM’16)» 67%playerscontinued≥5years» Youngerage+shorterdurationsymptoms=longercareer

• NFL(Menge,AJSM’17)» 87%returntoplay

» averaged33gameswithtotalcareer7.4seasons» Linemenlesslikelytoreturn

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Summary

• Labraltearsareusuallytheresultofrepetitivetraumaandalteredhipmorphology

• Arthroscopictreatmentprovidesgoodsymptomreliefandreturntosport

• Theeffectofsurgicaltreatmentonthedevelopmentofhiparthritisremainsunanswered

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Thank you

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