FAI – CURRENT RESULTS OF TREATMENTS

DEC 7, 2017
ARTHROPLASTY ROUNDS
 OUTLINE

• DEFINITION
• CLASSIFICATION
• PRESENTATION
• CLINICAL FINDINGS
• IMAGING
• MANAGEMENT
 OBJECTIVE

• DEFINITION • MANAGEMENT
• NON-SURGICAL
• CLASSIFICATION • PHYSIOTHERAPY
• PRESENTATION • SURGICAL
• SURGICAL DISLOCATION
• CLINICAL FINDINGS • TOTAL ARTHROSCOPIC
• DIAGNOSIS • INTERMEDIATES

• MANAGEMENT
 FEMORO-ACETABULAR IMPINGEMENT
• FAI IS A CLINICAL CONDITION THAT RESULTS FROM AN
INCONGRUENCY BETWEEN THE FEMORAL HEAD– NECK AND
ACETABULUM, WHICH CAUSES SECONDARY IMPINGEMENT AND
ASSOCIATED CHONDROLABRAL INJURY IN TERMINAL RANGES
OF MOTION1
 FEMORO-ACETABULAR IMPINGEMENT
• FAI IS A CLINICAL DIAGNOSIS WITH DISTINCT RADIO- GRAPHICAL FEATURES
WHERE AN UNDERLINING PATHO- LOGIC MECHANICAL DEFORMITY COMBINED
WITH REPETITIVE MOVEMENTS SUCH AS FLEXION AND/OR ROTATION CAUSES HIP
PAIN AND RESTRICTED HIP MOTION3
 TYPES

• CAM TYPE LESIONS

• PINCER TYPE LESIONS

• COMBINED IMPINGEMENT
(COMMONEST)
 TYPES

• CAM TYPE LESIONS • BONY PROTRUSION AT THE FEMORAL HEAD–

NECK JUNCTION RESULTING IN LOSS OF
• PINCER TYPE LESIONS OFFSET OR ASPHERICITY, FUNCTIONALLY
RESEMBLING A CAM1

• COMBINED IMPINGEMENT
(COMMONEST)
 TYPES

• CAM TYPE LESIONS

• PINCER TYPE LESIONS

• COMBINED IMPINGEMENT
(COMMONEST)
 TYPES

• CAM TYPE LESIONS

• PINCER TYPE LESIONS

• COMBINED IMPINGEMENT
(COMMONEST)

IMAGE CREDIT2
 TYPES

• CAM TYPE LESIONS • FOCAL OR GLOBAL OVERCOVERAGE OF

THE FEMORAL HEAD BY THE ACETABULUM
• PINCER TYPE LESIONS

• COMBINED IMPINGEMENT
(COMMONEST)
 TYPES

• CAM TYPE LESIONS

• PINCER TYPE LESIONS

• COMBINED IMPINGEMENT
(COMMONEST)

IMAGE CREDIT2
 TYPES

• CAM TYPE LESIONS

• PINCER TYPE LESIONS

• COMBINED IMPINGEMENT
(COMMONEST)
 PRESENTATION

• DEEP SEATED GROIN PAIN • HX:

• 20-40Y.O.
• PREVIOUS HIP PROBLEMS
• YOUNG ATHLETIC MALES (CAM DEFORMITY
(E.G. DDH) 14:1)
• MIDDLE AGED ACTIVE FEMALES (PINCER
DEFORMITY 1:3)
 PRESENTATION

• DEEP SEATED GROIN PAIN • GROIN/HIP PAIN WITH ACTIVITIES

• PAIN WORSE IN FLEXION (SITTING)
• PREVIOUS HIP PROBLEMS • MAY HAVE RELATED
(E.G. DDH) GLUTEAL/TROCHANTERIC/KNEE PAIN
• INCREASED OA RISK
 PHYSICAL EXAM3

• GAIT
• DEEP SQUAT TEST (CAM LESIONS)
• RESISTED SLR (STINCHFIELD MANEUVER)
• THOMAS TEST
• FADIR (ANTERIOR IMPINGEMENT)
• FABER
 IMAGING

• X-RAY

• CT

• MRI
 IMAGING

• X-RAY • AP VIEW OF PELVIS

• FALSE PROFILE VIEW
• CT
• CROSS TABLE LATERAL
• DUNN’S VIES (45/90)
• MRI
• FROG LET LATERAL VIEW
 X-RAY - DEFORMITY

• PISTOL GRIP DEFORMITY

AP PELVIS/HIP
CROSS TABLE LATERAL
DUNN VIEW
FALSE PROFILE VIEW
Beaule et el
 RADIOLOGICAL FINDINGS SUMMARY
Cam Pincer

Pistol grip Crossover sign

Asphericity Ischial spine sign

Decreased offset Abnormal acet. depth

Decreased offset ratio Increased CE Angles

Increased Alpha angle Coxa profunda/Protrusio

 IMAGING

• X-RAY

• CT

• MRI
 MRI WITH GADOLINIUM ARTHROGRAPHY AND CT

• CONFIRMATION OF DX
• MORE ACCURATE MEASUREMENTS OF
ALPHA ANGLE, FEMORAL HEAD-NECK
OFFSET RATIO, ETC
• SURGICAL PLANNING
• DETECTION OF LABRAL TEARS, CYSTS,
CARTILAGE DELAMINATION
X-RAY FINDINGS MALE
X-RAY FINDINGS FEMALE
 MANAGEMENT

• GOALS OF MANAGEMENT
• PAIN RELIEF
• RETURN TO PRIOR LEVEL OF FUNCTION/PAIN FREE ROM
• PREVENTION OF EARLY SECONDARY OA
• COMPLETE CORRECTION OF MECHANICAL DEFORMITY
• EARLY INTERVENTION
 MANAGEMENT - NONSURGICAL

• PHYSIOTHERAPY & ACTIVITY MODIFICATION

• NSAIDS
• GENERAL EXERCISE
• CHIROPRACTOR/MESSAGE
• INTRA-ARTICULAR INJECTIONS
 MANAGEMENT - SURGICAL

• ARTHROSCOPIC

• ARTHROSCOPY ASSISTED

• OPEN SURGERY
 ISSUES

• NO ESTABLISHED DIAGNOSTIC CRITERIA

• LACK OF GUIDELINES IN DETERMINING WHICH IMPINGEMENTS
REQUIRE REPAIR AND WHEN TO TREAT
• LACK OF HIGH QUALITY EVIDENCE FOR ANY TREATMENT MODALITY
 MANAGEMENT - SURGICAL

• ARTHROSCOPIC • ARTHROSCOPIC RESTORATION OF

IMPINGEMENT FREE MOTION FOR FAI IS
• ARTHROSCOPY ASSISTED GENERALLY SAFE.
• OPEN SURGERY
 MANAGEMENT - SURGICAL

• ARTHROSCOPIC • LEVEL III AND IV STUDIES OF ARTHROSCOPIC

TREATMENT OF FAI REPORT GOOD TO
• ARTHROSCOPY ASSISTED EXCELLENT RESULTS AMONG OUTCOME
MEASURES6
• OPEN SURGERY
• NO PUBLISHED RCT’S YET
 MANAGEMENT - SURGICAL

• ARTHROSCOPIC • COMPLICATIONS2:
• NERVE INJURY (PUDENDAL/
• ARTHROSCOPY ASSISTED LFCN/SCIATIC/FEMORAL)
• IATROGENIC CARTILAGE INJURY
• OPEN SURGERY
• INTRA ARTICULAR INSTRUMENT BREAKAGE
• FEMORAL NECK FRACTURE/AVN
• INCOMPLETE RESECTION
HIP ARTHROSCOPY IN PICTURE
HIP ARTHROSCOPY IN PICTURE
HIP ARTHROSCOPY IN PICTURE
HIP ARTHROSCOPY IN PICTURE
 MANAGEMENT - SURGICAL
• DEFICIENT ACETABULAR COVERAGE, NOTABLE
COXA VALGA, EXTENSIVE, NON-FOCAL,
CIRCUMFERENTIAL DEFORMITIES OR CERTAIN
• ARTHROSCOPIC
ACETABULUM SIDED DEFORMITIES (SUCH AS
• ARTHROSCOPY ASSISTED PROTRUSIO ACETABULI AND COXA PROFUNDA)1

• OPEN SURGERY
 MANAGEMENT - SURGICAL

• ARTHROSCOPIC • ANTERIOR APPROACH WITH ARTHROSCOPY

ASSISTANCE
• ARTHROSCOPY ASSISTED

• OPEN SURGERY • LIMITED USEFULNESS, ONLY FOR ANTERIOR

CAM LESIONS
 LOOKING FORWARD

• FIRST (AYENI AND BHANDARI 2012)

• UK FASHION (GRIFFIN 2012)
• FAIT (GLYNN-JONES 2013)
• NAUDIE (2011) – WESTERN
• HIPARTI (2016) (RISBERG, 2016 - ARTHROSCOPIC
SURGICAL PROCEDURES VS SHAM SURGERY FOR
PATIENTS WITH FEMOROACETABULAR
IMPINGEMENT AND/OR LABRAL TEARS)
 TAKE HOME

• FAI IS A RECENTLY DESCRIBED AND IMPORTANT MECHANISMS OF PRIMARY OSTEOARTHRITIS

IN YOUNG ADULTS
• TWO TYPES – CAM AND PINCER – MOST OFTEN CO-EXIST
• DIAGNOSIS IS BASED ON CLINICAL/RAD FINDINGS +/- FAILURE OF NON-OPERATIVE
MANAGEMENT
• TREATMENT IS GUIDED BY PATIENT CHARACTERISTICS AND SKILL AND EXPERIENCE OF
SURGEON
• LACK OF HIGH-LEVEL EVIDENCE TO SUGGEST NON-OP/OP (AND WHAT TYPE) FOR FAI
 REFERENCES:
1. NEW PERSPECTIVES ON FEMOROACETABULAR IMPINGEMENT SYNDROME, KHAN ET AL NATURE REVIEWS 2016

2. ARTHROSCOPIC TREATMENT OF FEMOROACETABULAR PINCER IMPINGEMENT, DIENST ET AL, OOT 2015

3. PATHOPHYSIOLOGY OF FEMOROACETABULAR IMPINGEMENT (FAI), GAVIN C.A. WOOD, HAMAD ALSHAHRANI, AND MICHEL TAYLOR, DIAGNOSIS AND
MANAGEMENT OF FEMOROACETABULAR IMPINGEMENT: AN EVIDENCE-BASED APPROACH. SPRINGER 2017

4. CLINICAL DIAGNOSIS OF FAI: AN EVIDENCE-BASED APPROACH TO HISTORY AND PHYSICAL EXAMINATION OF THE HIP, APARNA VISWANATH AND VIKAS
KHANDUJA, DIAGNOSIS AND MANAGEMENT OF FEMOROACETABULAR IMPINGEMENT: AN EVIDENCE-BASED APPROACH. SPRINGER 2017

5. EVIDENCE-BASED APPROACH TO THE NONOPERATIVE MANAGEMENT OF FAI NOLAN S. HORNER, AUSTIN E. MACDONALD, MICHAEL CATAPANO, DARREN DE
SA, OLUFEMI R. AYENI, AND RYAN WILLIAMS, DIAGNOSIS AND MANAGEMENT OF FEMOROACETABULAR IMPINGEMENT: AN EVIDENCE-BASED APPROACH.
SPRINGER 2017

6. ARTHROSCOPIC MANAGEMENT OF PINCER-TYPE IMPINGEMENT, JAMES B. COWAN, CHRISTOPHER M. LARSON, AND ASHEESH BEDI, DIAGNOSIS AND
MANAGEMENT OF FEMOROACETABULAR IMPINGEMENT: AN EVIDENCE-BASED APPROACH. SPRINGER 2017