femoroacetabular impingement in adolescents and young...

Orthopaedic Nursing • May/June 2009 • Volume 28 • Number 3 117

have a mixed type of FAI that presents with features ofboth the cam and pincer type. The abnormal contact orimpingement is believed to cause degenerative changesin the acetabular labrum and/or adjacent articularcartilage (Tanzer & Noiseux, 2004). If the underlyingcause of FAI is not addressed, labrum degeneration/separation and irreversible chondral damage can occurover time. Interestingly, the morphological changesseen in the labrum and cartilage with both cam andpincer hip impingement are similar to and consistentwith repetitive microtrauma and chronic degeneration(Clohisy & McClure, 2005). The etiology of FAI isbelieved to be multifactorial or possibly related to sub-clinical slipped capital femoral epiphysis (SCFE;Kassarjian et al., 2005). The association between FAIand SCFE is believed to be due to reduced clearance ofthe femoral head against the acetabular rim. There areactually a number of conditions that can predispose apatient to FAI including Legg-Calve-Perthes disease,developmental hip dysplasia, SCFE, avascular necrosisof the femoral head, ununited femoral neck fractures,coxa vara and profunda, protrusion acetabuli, andacetabular retroversion (Ganz et al., 2003).

Femoroacetabular impingement initially leads tohypertrophy (thickening) of the anterior–superiorlabrum with intrasubstance degeneration (fraying).Over time, delamination of the acetabular cartilage ofthe superior acetabular rim-labral junction occurs, anddegenerative labral tears are often produced anteriorlyby repetitive compression and sheer forces. As severity

Femoroacetabular impingement (FAI) is a recently describedhip disorder resulting from an abnormal morphologybetween the proximal femur and acetabulum (socket). It isnow recognized as a cause of hip pain in adolescents andyoung adults, and research has shown that it may also leadto early degenerative changes and osteoarthritis.Femoroacetabular impingement as a cause of precociouship arthrosis was originally described by Ganz et al. in 2001,and a quick literature search on this topic will confirm that ithas become a topic of cutting edge research within the or-thopaedic community. The abnormal morphology in FAI re-sults in increased hip contact forces with hip motion, espe-cially flexion. This results in abnormal contact that can leadto acetabular labral tears and cartilaginous injury. Earlydiagnosis and treatment may possibly delay the future onsetof hip arthritis.

Although the precise cause of FAI is not well under-stood, the condition has become increasingly recognized asa cause of hip pain in active adolescents and young adults.The purpose of this article is to outline the history, physicalexamination and radiographic findings, and current conser-vative and surgical treatment modalities for FAI.

Overview and Etiology of FAIThe normal anatomy of the hip ball and socket joint al-lows for a very wide range of motion (see Table 1). It isbelieved that decreased joint clearance between thefemoral neck and the acetabulum predisposes a patientto the development of FAI. Depending on clinical andradiographic findings, 2 types of impingement are rec-ognized: pincer impingement is the acetabular (socket)cause of FAI and is characterized by focal or generalovercoverage of the femoral head (see Figure 1; acetab-ular retroversion or coxa profunda). The overcoveragetypically exists along the front-top rim of the acetabu-lum and can cause pinching of the labrum at thehead–neck junction. Cam impingement is the femoralcause of FAI and is due to an aspherical portion of thefemoral head (see Figure 2). The aspherical shape of thefemur is believed to contribute to increased contactbetween the femoral head and the acetabulum. Mostrecent studies have shown that the majority of patients

Erin S. Hart, RN, MS, CPNP, Department of Orthopaedic Surgery,Massachusetts General Hospital for Children, Yawkey Center forOutpatient Care, Boston.

Umesh S. Metkar, MD, Department of Orthopaedic Surgery,Massachusetts General Hospital for Children, Yawkey Center forOutpatient Care, Boston.

Gleeson N. Rebello, MD, Department of Orthopaedic Surgery,Massachusetts General Hospital for Children, Yawkey Center forOutpatient Care, Boston.

Brian E. Grottkau, MD, Department of Orthopaedic Surgery,Massachusetts General Hospital for Children, Yawkey Center forOutpatient Care, Boston.

The authors have disclosed that they have no financial relationships re-lated to this article.

Femoroacetabular Impingement in Adolescents and Young Adults

Erin S. Hart ▼ Umesh S. Metkar ▼ Gleeson N. Rebello ▼ Brian E. Grottkau

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of the disease progresses, the entire labrum can be-come degenerative with further delamination of the ac-etabular articular cartilage and subsequent wear dam-age to the anterior portion of the femoral head. The endresult of this chronic process can be the development ofglobal hip arthrosis.

Clinical PresentationPatients with FAI are generally adolescents or youngadults between the ages of 18 and 35 years. The typicalpatient with FAI will present with anterior groin painand pain with hip rotation (particularly flexion and in-ternal rotation), in the sitting position, or during orafter sports activities. The medical history should in-clude the age and overall health of the patient, a de-scription of the pain characteristics, the patient’s activ-ity level, associated comorbidities, and any previouship disease or related treatments. Sink, Gralla, Ryba,and Dayton (2008) recently studied 35 adolescent pa-tients (age 13–18 years) with FAI and found that thechief complaint that was present in all patients was an-terior groin pain. Patients with FAI are often young andathletic and are often involved in activities that requirerepetitive hip flexion (dance, running). Typically, thepatient is aware of a subtle decreased range of motionor stiffness long before symptoms appear. The painmay be localized anteriorly and exacerbated in certainhip positions, depending on the location of the lesion.In addition, it is important to remember that hip paincan often be referred to the knee.

Femoroacetabular impingement is often bilateral butis often symptomatic on only one side (Tannast,Siebenrock, & Anderson, 2007). Many athletes with FAI

report difficulty with cutting and lateral movements andalso with starting and stopping. In addition, many pa-tients with FAI report pain after sitting for a prolongedperiod of time (prolonged hip flexion) and when climb-ing stairs. Some patients with FAI and an acetabularlabral tear report mechanical symptoms such as painfulclicking, locking, or giving way of the hip. Patients mayalso describe a trochanteric pain radiating to the lateralthigh. The physical examination usually demonstratesdecreased flexion, internal and external rotation, and ab-duction (Kubiak-Langer, Tannast, Murphy, Siebenrock,& Langlotz, 2007). There is often limited internal rota-tion of the hip that is out of proportion with other rangeof motion deficits (Bathala, Bancroft, Peterson, &Ortiguera, 2007).

The classic finding in FAI during physical examina-tion is a positive anterior impingement sign (seeFigure 3). A positive impingement sign is present foranterior FAI if the forced internal rotation/adductionin 90� of hip flexion is reproducibly painful. This test isdone with the patient supine; the hip is internally ro-tated as it is passively flexed to approximately 90� andadducted. Many studies have consistently shown thatvirtually all patients with cam FAI will have a positiveimpingement test on examination. Restricted internalrotation in hip flexion is due to osseous impingementof the anterolateral femoral head–neck junction withthe posteroinferior rim of the acetabulum.

Radiographic FindingsAlthough the diagnosis of FAI is weighed heavily on thehistory and physical examination, radiographic studiesare used to corroborate these findings. Standard radi-ographic evaluation for FAI includes an anteroposteriorpelvis view, false profile view, frog lateral view, andcross-table lateral view of the hip. The frog leg lateral ra-diograph gives providers an accurate view of thefemoral head–neck offset in patients with FAI. It is im-portant to note that proper technique for the radi-ographs is required, as poorly obtained images may leadto over- or underestimation of the degree of disease(Tannast et al., 2007). In patients with FAI, standard ra-diographs may appear normal at first glance; however,careful examination may often reveal subtle abnormali-ties. Providers should closely examine the femoralhead–neck region for abnormalities. The femoral head

118 Orthopaedic Nursing • May/June 2009 • Volume 28 • Number 3

FIGURE 1. Pincer impingement injury patterns. From D. King, retrieved from www.kingorthopaedic.com. Reprinted with permissionfrom the author.

TABLE 1. NORMAL HIP RANGE OF MOTION

Flexion � 0�–125� (To gain a true picture of hip flexion, i.e.,movement between the pelvis and femur in the hip joint, theopposite thigh should be extended to minimize motion be-tween the pelvis and the spine.)Extension � 0�–30�

Adduction � 0�–25�

Abduction � 0�–45�

External rotation � 0�–60�

Internal rotation � 0�–40�

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offset is the difference between the widest diameter ofthe femoral head, the most prominent part of thefemoral neck. Patients with decreased offset will oftenhave a lack of the normal waisting of the femoralhead–neck junction, which can lead to cam impinge-ment (see Figure 4). Radiographic signs of pincer im-pingement include acetabular retroversion and evi-dence of impaction between the anterosuperioracetabulum and anterior femoral neck (Beaule,Zaragoza, Motamedi, Copelan, & Dorey, 2005).Acetabular retroversion is often diagnosed by the pres-ence of the “crossover” or figure-of-eight sign. More re-cently, acetabular retroversion is recognized radi-ographically by the prominence of the ischial spineprojecting into the pelvis (Kulberer et al., 2008).

Femoroacetabular impingement is often further im-aged with both magnetic resonance imaging (MRI) andMRI-arthrogram (MRA), which can provide detailedviews of the labrum and acetabular cartilage. The ad-vantage of an MRA is that the intra-articular contrast

material distends the joint, separates intra-articularstructures, and provides internal contrast to delineatethe labrum and cartilage (Kassarjian et al., 2005).Magnetic resonance imaging findings in patients withFAI can include abnormalities in the acetabular bone,labrum, and articular cartilage. James et al. (2006) haverecently shown that the majority of the abnormalitiesare located peripherally at the labral–chondral junction.The articular cartilage can show a variety of changeswith FAI ranging from slight chondral softening to full-thickness defects. These changes usually occur in the an-terosuperior aspect of the acetabulum; however, recentresearch has shown that patients with pincer FAI mayhave cartilage lesions in the posteroinferior aspect of theacetabulum (Pfirrmann et al., 2006). Kassarjian et al.(2005) examined MRA findings in patients with cam-type FAI and consistently found anterosuperior labraltears, anterosuperior cartilage lesions, and an abnormalfemoral head–neck junction/offset (see Figure 5A & B).The identification of the abnormal head–neck junction iscritical because if only the labral and cartilage issues areidentified and treated, the underlying cause of impinge-ment will remain and can cause persistent pain anddegenerative changes. Many young patients have been


FIGURE 2. Cam impingement injury patterns. From D. King, retrieved from www.kingorthopaedic.com. Reprinted with permissionfrom the author.

FIGURE 3. Anterior impingement sign—positive if pain withflexion and internal rotation. FIGURE 4. Anteroposterior x-ray of pelvis with cam impingement.

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treated for isolated labral tears without treatment of theactual impingement, which may explain some of thepoor outcomes seen in some reports.

Conservative TreatmentNonsurgical treatment should always be consideredwhen managing patients with FAI. The symptoms associ-ated with FAI can often resolve with rest, activity modifi-cation, physical therapy, and anti-inflammatory medica-tion. Initial conservative treatment involves temporarilylimiting or stopping the activity that aggravated thesymptoms (dance, running, etc.). Physical therapy forFAI is often focused on core stability exercises andstrengthening. It is also helpful to work on hip flexorstretching, as it is not uncommon to have concurrent iliopsoas (primary hip flexor) tightness associated withimpingement. It may actually be quite difficult forproviders to differentiate iliopsoas pain from FAI and an-terior labral tear pain. Another conservative treatmentoption for patients with FAI is a diagnostic/therapeuticinjection. The injection is usually done using radi-ographic guidance and involves intra-articular adminis-tration of lidocaine/bupivacaine (Marcaine) and a corti-costeroid. This injection can be very useful to help clarifythat the patient’s pain is, in fact, coming from within thehip joint. The pain relief, even if only temporary, canoften allow for improved physical therapy. The majorityof these patients are young and eager to get back intosports and athletic endeavors; however, providers mustremember that continued FAI can lead to progression ofthe destructive process and advancement of labral andchondral lesions.

Surgical TreatmentBecause FAI is a relatively newly recognized entity,treatment techniques are actively evolving. Surgical

treatment of FAI should relieve any mechanical im-pingement as well as treat any intra-articular injury thatmay be present. The main goal of surgery is to improvethe clearance for hip motion and alleviate the femoralimpingement against the acetabular rim (Lavigne et al.,2004). Current treatment of FAI in adolescents andadults includes open surgical dislocation and hiparthroscopy. Treatment of FAI, whether open or arthro-scopic, should have two goals—short-term relief of pre-operative symptoms, with a longer-term goal to reducethe chance of developing osteoarthritis (Ganz et al.,2003).

Open surgical dislocation was pioneered by ReinholdGanz et al. (2001) and early and mid-term success hasbeen reported. The blood supply to the femoral head wasstudied extensively so that it could be preserved duringthe surgical hip dislocation procedure. Preserving the tenuous blood supply to the femoral head is impor-tant because it significantly decreases the chance ofdeveloping secondary osteonecrosis (avascular necrosis).Surgical dislocation of the hip provides a full 360� viewof the femoral head and the acetabulum for inspection(Labigne et al., 2004). The specific type of treatmentthen depends on the pattern and extent of impingementdisease but usually involves femoral osteoplasty (re-moval of the prominent bump) and debridement/repairof the acetabulum labrum. Dr. Ganz has had extensiveclinical observations with more than 600 surgical dislo-cations of the hip and has observed that FAI results inlesions of the joint and acts as an initiator for early de-generative disease of the hip. Dr. Rebello et al. (2009)retrospectively reviewed case records, radiographs, andpre-/posttreatment questionnaires of 81 adolescent pa-tients (84 hips) treated with surgical hip dislocation.The average patient age was 16 years and the minimumfollow-up was 12 months (average 41.6 months). Theyfound an overall low rate of complications from thesurgical hip dislocation procedures. Complications


FIGURE 5 A & B. MR arthrogram showing abnormal head–neck junction with classic anterosuperior labral tears.

(A) (B)

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included four cases of osteonecrosis (three after femoralneck osteotomy). They concluded that surgical disloca-tion of the hip is a demanding procedure but one thatoffers sufficient advantages in assessing and treatingcomplex deformities of the hip including FAI (Rebello et al., 2009).

It is important to note that if only the labral and/orcartilaginous lesions are addressed surgically, the os-seous abnormalities will continue to result in FAI andthus continue to damage the cartilage and labrum(Kassarjian, Cerezal, & Llopis, 2006). This can lead topersistent pain and possible progression of degenerativechanges. Therefore, any surgical procedure must ad-dress both the osseous abnormalities causing the FAIand any labral or cartilage lesion that results from it. Ifthere are already advanced degenerative changes seenin the hip (osteoarthritis), treatment often consists ofarthroplasty (joint replacement) because results of min-imally invasive correctional surgery have been very dis-appointing. Patients with advanced cartilage damage atthe time of surgery have poorer outcomes and often re-quire subsequent total hip arthroplasty (Peters &Erikson, 2006). Therefore, it is very important to havehigh-quality preoperative imaging to determine theamount and severity of degenerative changes.

In the past 2–3 years, hip arthroscopy and less inva-sive surgical procedures have allowed for significantlyfaster recovery and decreased surgical morbidity. Acombined approach of arthroscopy and limited opentechniques has also recently been described (Clohisy &McClure, 2005). The number of hip arthroscopy proce-dures has been increasing on an annual basis. Hiparthroscopy can have both a diagnostic and a therapeu-tic role in evaluating hip pain of unknown etiology. Themost common indications for hip arthroscopy includeacetabular labral disease, focal articular cartilage le-sions, FAI, loose bodies, and synovial disorders (Clohisyet al., 2008). Contraindications to hip arthroscopy in-clude any clinical situation that prevents safe distrac-tion of the hip joint. Moderate traction is required dur-ing hip arthroscopy (due to the confined joint space) butshould be minimized to avoid risk to the pudendal,femoral, and sciatic nerves. Relative contraindicationsto hip arthroscopy include altered anatomy precludingsafe portal placement (previous surgery), open wounds,severe obesity, and infection.

Philippon, Yen, Briggs, Kuppersmith, and Maxwell(2008) recently studied 16 adolescent patients with FAI(age 11–16 years) and found excellent improvement infunction and a high level of patient/family satisfactionafter hip arthroscopy. They found that pediatric andadolescent athletes with repetitive flexion, flexion–abduction, or extension–external rotation activitiessuch as dancing, gymnastics, and skating had a higherrisk of developing anterior labral tears. The surgicaltreatment of FAI was aimed at restoring a normalfemoral head–neck offset and/or removing excessive ac-etabular coverage. In addition, any labral tears or carti-laginous lesions were repaired or débrided arthroscopi-cally. Subjective data were collected from each patientduring his or her initial visit and at follow-up aftersurgery. Subjective data included the modified Harriship score, patient satisfaction, and hip outcome score

activities of daily living and sports subscales. The meanpreoperative modified Harris hip sore improved 35 points,the hip outcome score improved 56 points, and the meanpatient satisfaction score was 9 out of 10 (Philipponet al., 2008). Limitations of this study are its very smallsize and the lack of physical examination and postopera-tive radiographic data. More studies are needed to assessand compare the different surgical treatments of FAI.There are no current studies that directly compare arthro-scopic with open treatment of FAI in adolescents andyoung adults, and more comparative and evaluativestudies are needed. Future improvement in arthroscopicand minimally invasive techniques combined with thesignificant advances in radiographic imaging should leadto more effective management of FAI.

Case StudyJC is a 15 � 7-year-old girl referred to the pediatric or-thopaedic clinic for examination of chronic bilateral hippain, right much greater than left. She is status post pin-ning for bilateral SCFE. She had the percutaneous pin-ning done in July 2008. Postoperatively, she has hadchronic persistent hip pain and decreased range of mo-tion. She was unable to participate in any sports and wasable to tolerate sitting only for 5–10 min. Medical historywas significant for obesity (body mass index 40), Type IIdiabetes mellitus, and mild intermittent asthma. Shecurrently takes metformin, fluticasone and salmeterol(Advair), and albuterol metered-dose inhaler.

BRIEF PHYSICAL EXAMINATION

She walks with her feet externally rotated and has an an-talgic, lurching gait. Examination of her left hip revealship flexion of 90�, internal rotation of �20�, and externalrotation of 40�. The right hip has approximately 45� offlexion (limited by pain), internal rotation of �40�, andexternal rotation of 20�. There is mild weakness on re-sisted hip abduction. She has well-healed percutaneousincisions status post pinning for the SCFE. She has mildhamstring tightness bilaterally. Neurological examina-tion of the lower extremity is normal.

CASE STUDY RADIOGRAPHS

Anteroposterior/frog lateral x-rays of the hip were ob-tained (see Figures 6A and B), which demonstrate thatshe is status post pinning for bilateral SCFE. There isdecreased femoral head–neck offset and evidence ofCAM impingement. A computed tomography scan ofher pelvis was then done, which demonstrated de-creased anteversion of the proximal femur with 6� onthe right and 13� on the left (average 15�; see Figure 7).There was also evidence of CAM FAI with decreasedfemoral head–neck offset and bilateral mild joint spacenarrowing.

CASE STUDY SURGERY

Based on the history, physical examination, and radi-ographic findings, the decision was made to proceedwith a right proximal femoral head–neck osteochon-droplasty via a right hip surgical dislocation. The goalsof surgery were to decrease pain and improve range of


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motion, decrease the impingement, and decrease thechances for early degenerative arthritis of the hip.

SURGICAL PROCEDURE/OPERATIVE NOTE

Right hip surgical dislocation, proximal head–neck os-teochondroplasty, right trochanteric osteotomy withfixation, right proximal femur hardware removal, andcomplex closure.

OPERATIVE NOTE

The patient was given a combination of epidural andgeneral anesthesia and placed lateral on a Jackson tablewith the help of a pegboard. Great care was taken to en-sure that all bony prominences as well as areas wherenerves run superficially were padded. The patient wasprepped and draped in the usual fashion. An incisionwas made in the middle of her thigh from a point 10 cmdistal to her greater trochanter that ran up proximallyto the greater trochanter along the shaft of the femurand curved posteriorly toward the posterior superioriliac spine (PSIS) for another 8 cm. After cuttingthrough layers of subcutaneous adipose tissue, the ili-otibial band (IT) was incised in a longitudinal fashionand the gluteus maximus was split in the direction of itsfibers, thus exposing the greater trochanter. The ar-borescence of vessels on the greater trochanter werenoted, which indicates the position of the deep branchof the medial circumflex femoral artery. The intervalbetween the piriformis and the gluteus minimus wasalso noted more proximally. The vastus lateralis fascia

was incised and the muscle was peeled off the shaft ofthe femur extraperiosteally from a posterior to anteriorfashion. The trochanteric osteotomy was then markedand performed with an osteotome. The osteotomythickness was approximately 1.5 cm and was just madelateral to the trochanteric groove and was continuouswith the vastus lateralis fascia. The gluteus medius wasleft attached to the greater trochanter along with thepart of the minimus, which was peeled off the capsule.The interval between the minimus and the piriformiswas then explored and elaborated. The gluteus min-imus was carefully peeled off the capsule of the hipjoint superiorly taking care to ensure that we were an-terior and superior to the piriformis. Anteriorly the vas-tus medialis and intermedius were peeled off the cap-sule of the hip joint. At this time a bump was used toexternally and internally rotate and position the hip toobtain access to all these various areas. Blunt dissectionwas also performed with a Cobb and sharp dissectionwith a knife. The capsule was exposed all the way up tothe acetabular rim. Once that was done, an anterior partof the Z-shaped incision was made on the capsule. Thecapsule was found to be extremely adherent to theunderlying bone most probably because of the prior fix-ation with a screw of the slipped femoral epiphysis. Thescrew was found to be extremely protuberant andimpinging against the acetabulum and deforming thelabrum. A Z-shaped incision made of the capsule wascompleted, taking care to ensure that the labrum of theacetabulum was left intact. We tried to remove theimpinging screw without any success, with screw-drivers as well as screw removal apparatus utilizedunsuccessfully. We finally took a Diamond bur andtrimmed the impinging part of the screw off, leaving theshank inside.

Prior to trimming of the femoral head and neck, thejoint was dislocated by pulling up on the femoral neckwith a bone hook and cutting the ligamentum teres witha curved scissors. Then we turned our attention to thepart of the femoral head and neck that was impingingand deforming the labrum. That area was trimmed withan osteotome and smoothed down with a bur. Care was


FIGURE 7. Computed tomography scan of pelvis demonstrat-ing decreased anteversion and evidence of cam impingement.

FIGURE 6 A & B. Anteroposterior/lateral x-rays of hip status post pinning for bilateral slipped capital femoral epiphysis showing evidence of cam impingement.

(A) (B)

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taken to ensure that we did not extend into the superiorpart of the neck where the blood vessels entered thefemoral head. Once the femoral head and neck regionwas trimmed, bleeding was controlled by spreading bonewax over that area. The joint was copiously irrigated toremove all debris as well as possible metal fragmentsfrom the screw. The joint was then relocated and therange of motion was found to be much better than pre-operatively. We were able to flex the hip to almost 90� andinternally rotate it to 5� and externally rotate it to 70�. Thecapsule was loosely sutured with UR-6 2-0 Vicryl sutures.The trochanter was then reattached with two screws of65 mm and 3.5 mm, respectively, which had bicorticalpurchase. The trochanteric fragment got slightlydisplaced when we tightened the screws I chose to main-tain the bone in that position because I did not want tomake multiple holes in the trochanteric piece. The vastuslateralis fascia was then repaired with 3-0 Vicryl. The ITband was closed with #1 Vicryl and the closure extendedinto the fascia of the gluteus maximus. Subcutaneous tis-sue was closed with 2-0 Vicryl. One medium HemoVacdrain was placed under the IT band and one drain waskept in the subcutaneous tissue. Skin was closed with 3-0Monocryl. Postoperative C-arm fluoroscopic images wereobtained (see Figure 8A & B). Anesthesia was then re-versed and patient was moved onto a regular bed after per-

forming dressing under sterile circumstances. The patientwas found to be neurovascularly intact in both extremitiesand then moved to the postanesthesia recovery room instable condition.

POSTOPERATIVE PLAN

The patient was placed into a continuous passive motiondevice postoperatively with settings at 30 (extension) to70 (flexion) degrees. The continuous passive motiondevice is often used in the first 2–3 weeks after surgeryto facilitate early range of motion and prevent excessivestiffness. The patient was instructed on partial weightbearing, using crutches. She was instructed to avoidany active abduction and also any adduction or exter-nal rotation of the hip. She was transitioned to oral painmedication and was discharged home on postoperativeday 3. She will be seen for a follow-up visit at 2, 8, and12 weeks postoperation for repeat examination and fol-low-up x-rays. The plan is for partial weight bearing for6–8 weeks and then progress to weight bearing as toler-ated once the x-rays confirm healing of the trochantericosteotomy (see Figure 9).

DiscussionFemoroacetabular impingement is now a recognizedcause of hip pain in adolescents and young adults.Although long-term results are unknown, initial re-search suggests that recognition of FAI with early inter-vention before the degenerative process has advancedmay possibly delay the onset of osteoarthritis.Advancements in the ability of MRI/MRA to identifylabral and chondral pathology should greatly improveour understanding of the natural history of FAI (Parvizi,Leunig, & Ganz, 2007). Nonsurgical conservative thera-pies should be the initial course of treatment; however,recent studies have shown minimally invasive arthro-scopic techniques to be very successful with excellentshort-term results. The role of surgery for FAI in youngpatients is an evolving process and now includes mini-mally invasive arthroscopic procedures. More studiesare needed to examine and compare the various surgicaland nonsurgical options for patients with FAI.


FIGURE 8 A & B. Intraoperative fluoroscopic radiographs status post right trochanteric osteotomy with fixation.

FIGURE 9. Anteroposterior x-ray of right hip 6 weeks status postright trochanteric osteotomy.

(A) (B)

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Philippon, M. J., Yen, Y. M., Briggs, K. K., Kuppersmith, D.A., & Maxwell, R. B. (2008). Early outcomes after hiparthroscopy for femoroacetabular impingement in theathletic adolescent patient: A preliminary report.Journal of Pediatric Orthopedics, 28(7), 705–710.

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Tannast, M., Siebenrock, K. A., & Anderson, S. E. (2007). Femoroacetabular impingement: Radiographicdiagnosis—what the radiologist should know. AJR.American Journal of Roentgenology, 188(6), 1540–1552.

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For more than 28 additional continuing nursing education articles related to orthopaedic topics, go to www.nursingcenter.com/ce

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