Femoroacetabular impingement (FAI)

Femoroacetabular Impingement
(FAI)
Bahaa' Ali Kornah
• Professor of Orthopedic Surgery
• Faculty of Medicine
• Al Azhar university
bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

Dr. Bahaa Ali Kornah
Prof.. Of Orthopedic
Al-Azhar University
Cairo - Egypt
Bahaa Kornah. Al-Azhar Un. Cairo EGYPT
‫وبركاته‬ ‫هللا‬ ‫ورحمة‬ ‫عليكم‬ ‫السالم‬

Introduction
abnormal contact between the femur
and acetabulum which leads to labral
damage and various degrees of
chondral injury Cause of early
degenerative changes in young
adult hips
Reinold Ganz , Javad Parvizzi
, Martin Beck , Michael
Leunig University of Bern
Switzerland

Introduction
• Abnormal impingement(abutment) between
the femoral head–neck junction and the
acetabular rim
• apparent with participation
in activities requiring
extreme range of motion
(ballet, gymnastics, martial arts)

Patients with Healthy, active adults.
Ages 25 – 50 yrs.' old.
 Athletic
 activities,
 extreme range of
hip motion,
 deep hip flexion,
 pivoting of the
hip,
 Ice Hockey,
Martial Arts,
Football, Golf
Track – field
gymnastics
jumpers, runners

Pathoanatomic
 Types
 Cam (femoral based disorder )
 Pincer (Acetabular based disorder )
 Mixed
 (Lavigne et al.,2004)

CAM FAI
Cam Comes from a dutch word
meaning " cog " .
It is caused by jamming of an
abnormal femoral head with
increasing radius into the
acetabulum during forceful
motion, especially flexion . (Ito et
al.,2001)
refers to femoral based
disorder usually in young
athletic males

Pathomechanism of
Cam FAI
In extension: The asphericity of
the femoral head does not
interfer with the acetabular
labrum.
In flexion: The acetabular labrum
is lifted by asphericity of the
femoral head and the acetabular
cartilage is compressed. (Beck et
al.,2004)

•Cam impingement
•characterized by any of the following
 decreased head-to-neck ratio
 aspherical femoral head
 decreased femoral offset
 femoral neck retroversion
•this sphericity mismatch causes shearing at
the chondro-labral junction, leading
to cartilage delamination and labral
separation

‘’cam’’ type :
 non spherical head
 reduce of head –neck offset
 widening of head –neck
junction
 ’pistol –grip’’ deformity
‘

‘’Cam’’ type :
damage to the antero –
superior area of the
acetabulum
(1 o’clock)
M : F – 14 : 1

Pincer FAI
 Pincer comes from a
french word meaning " to
pinch ".The abutment is the
result of acetabular
abnormality which Often
general (coxa profunda) or
local anterior over coverage
(acetabular retroversion).
(Tanzer et al.,2004)
 anterosuperior quadrant

Pathomechanism of
Pincer FAI
In extension:The deep socket
not interfer with movement of
the hip.
In flexion: As the femoral neck
approaches the acetabular rim
,the labrum is crushed together
with a narrow band of the
acetabular cartilage. If the
femoral head is levered out of
the socket, a posteroinferior
'conter-coup' lesion occurs.
(Lavigne et al.,2004)

‘’pincer type’’ :
1. Excessive acetabular
cover (coxa profunda)
2. acetabular retroversion
3. Protrusio acetabuli

Mixed Cam-Pincer FAI
Cam and pincer FAI rarely occur
in isolation. Most have a
combination of both. The
damage to the cartilage in
these cases is usually a
combination of the two
patterns of damage. (Beck et
al.,2005)
’Mixed’’ type is the most
usual

•Combined Cam/Pincer
impingement
•can include both patient populations
•refers to combinations of above (up to 80%)
•SCFE deformity causes variable patterns of
impingement

Femoro-acetabular impingement
Pincer impingement
 More common in middle aged women
 Small area of posterior chondral damage
 More benign
CAM impingement
 More common in young athletic males
 Deeper extensive chondral damage

PREDISPOSING FACTORS
 YOUNG
 ...often ACTIVE
 ...usually MALE
 ...mostly

•
 •Legg-Calve-Perthes disease
 Congenital hip dysplasia
 Slipped capital femoral ephiphysis
 Avascular necrosis
 Malunited fractures
 Acetabular protrusion
 Elliptical femoral head
 Retroverted acetabulum
 Prominent femoral head-neck junction
•
•
•
•
•
•
•
•
Predisposing factors to FAI

-Proposed etiologies
1. Abnormal hip
morphology (Abnormal
anatomy )
2. Normal hip
morphology but
excessive range of hip
movement

Patients with minor trauma
or
underlying hip pathology
 Post –traumatic free loss bodies into the joint ,
 lateralimpact injurytothegrater trochanter
 Legg –Calve –Perthes
 Slipped femoral headepiphysis
 Asphericalhead
 Previousfemoral neck fracture (decreased head –
neck offset , wideningof thefemoral neck)

ACTIVITIES
Football,Dancing ,MartialArts

MEANING...
** Large Hip ROM
** Axial Loading of Hip
** Torsional Forces

physiologie articulaire kapandji
I.A. Kapandji bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

Hip Anatomy
Polyaxial ‘ball & socket’
synovial joint
Stability v Mobility
 Labrum
 Ligaments
 Iliofemoral / Pubofemoral
/ Ischiofemoral
 Neck-shaft 125-135°
 FNA 8-15°

Anatomical
structures:
The Hip joint consists of
Acetabulum, Labrum, Head
– Neck junction of Femur ,
Articular capsule
Labrum :
fibrocartilaginous structure,
deepens the articular cavity of
acetabulum , increases stability
Head –Neck junction :is an
intracapsular structure

Femoral Head :Almost
spherical, covered by
the labrum at it’s
2/3,beyond the point of
it’s equator
The articular cartilage of
the acetabulum and of the
femoral head are thicker
at the antero – superior
point, region of the
greater forces that the
acetabulum endures
during the abutmen
(impingement) of the
femoral head

Diagnosis & Differential
Diagnosis

Clinical :
 patient presentswithgroinpain (anteriorhip pain)
•Pain over trochanters
•Pain with flexion and internal rotation
,limitation of hip movement
•Usually unilateral
•Starts after mild trauma
 usually young and/or middle aged active adults
with minortraumaorno trauma history
 increasing pain with activities , prolonged sitting
 difficultyto get in–out of the car, arisingfromseat
or Bed
 difficultyto do the shoes , socks

patient shows his hip
with the grip ‘’C’’ sign
a C sign with their hand
over the painful hip which
is a very specific sign for
hip disease

Femoro-acetabular
impingement
Clinical assessment
Anterior FAI
 Pain in Flexion,Adduction and IR
Posterior FAI
 Pain in Extension, External rotation

SYMPTOMS

WALKING
PATTERNS

ANTALGIC GAIT

TRENDELENBURG GAIT

POSITIVE IMPINGEMENT TEST
90%ofFAIsuffererstestpositive

FALSE POSITIVES
(OTHER POSSIBLE CAUSES)
• Hip dysplasia Avascular necrosis
• Slipped Capital Femoral Epiphysis
• Legg-Calvé-Perthes Disease

Special tests
Tests for impingement

Tests to assess impingement
 The FABER
(Patrick's)Test
 FABERE (Flexion-Abduction-External
rotation-Extension) test
 Patient position – Supine
 Procedure- Put the affected limb on the
opposite limb in the Flexion-Abduction-External
rotation (FABER) position or Figure 4 position.
Apply hand over the medial aspect of knee and
force the hip into full abduction and extension.
 TEND TO STRESS THE IPSILATERAL
S-I JOINT
 PAIN IS POSTERIOR IN S-I ARTHRITIS
 PAIN IS ANTERIOR IN HIP ARTHRITIS

 Scour test
 Patient position- Supine
 Procedure- Done by moving the hip in an arc

 Stinchfield test (Resisted
SLR test)
 Patient position- Supine
 Procedure-Ask the patient to actively
flex the hip to 30 degrees while keeping
the knee in extension and to hold the
position. Apply resistance just proximal
to the knee.
 Interpretation- Pain felt in the groin is
suggestive of intra articular pathology.

 FADDIR (Flexion-
Adduction-Internal
rotation) test or Anterior
impingement test
 Patient position –
Supine
 Procedure- Put the affected limb in the
Flexion-Adduction-Internal rotation
(FADDIR) position.Apply hand over the
anterolateral aspect of knee and force the
hip into full adduction and internal rotation.
 Interpretation- If there is catching type of
pain then test is positive.

Tests to assess impingement Posterior impingement test
(Hyperextension-Abduction-
External rotation (HEABER test))
 Patient position – Prone
 Procedure- Passively place the affected hip in the
Hyperextension-Abduction-External rotation (HEABER)
position.
 Interpretation- If there is catching type of pain then test
is positive.

 McCarthy test
 Patient position-
Supine on the
couch.
 Procedure- Flex both hips fully.
Extend the affected hip.
 Interpretation- If patient
complains of catching pain the
test is positive.

XRAY
MRI
MRA
CT SCAN

Imaging :
 AP with true lateral
view (hip placed in
15 degrees of
internal rotation)
 ’pistol -grip’’
deformity
 non spherical head
 free intra–articular
bodies
‘

Pincer type FAI
•Pincer type of FAI
•Middle to older aged women (40)
•Seen in ballet dancers
•acetabular abnormality = Acetabular
overcoverage
•Primary radiographic signs
 Coxa profunda
 Protrusio acetabuli
 Acetabular retroversion
 Decreased extrusion index
 Neutral acetabular index
 Posterior wall sign
•Posterior inferior cartilage abrasion due to
contracoup injury
Normal
Pincer

Coxa Profunda
•Coxa profunda – floor of fossa
acetabuli overlaps ilioischial line
medially
•Pincer type FAI
•Creates deep acetabulum
•General overcoverage
•Normal

Protrusio acetabuli
•Protrusio acetabuli – occurs
when the femoral head overlaps
the ilioischial line medially
•Pincer type FAI
•Creates deep acetabulum
•General overcoverage
•Normal

Lateral center edge angle
•Lateral center edge angle – pincer type FAI
•Normal is between 25 and 39 degrees
•Increases with deeper acetabulum and more overcoverage
Protrusio acetabuli

Decreased extrusion index
•Decreased extrusion index – pincer type FAI
•(E / [A + E])
•25 % in normal subjects
•Decreases as femoral head becomes “more covered.”

Acetabular index
•Acetabular index – pincer type FAI
•Should be positive
•Becomes negative as acetabulum “deepens”
Positive AI Negative AI in protrusio acetabuli

Acetabular Retroversion
•Acetabular retroversion – pincer type FAI
•Cross over sign
•Focal acetabular overcoverage
•Cranial anterior wall line projects laterally
•Anterior/anterolateral labrum is obstacle to flexion and internal rotation
•Distinguish from deficient posterior wall

•crossover sign
•indicates acetabular
retroversion in Pincer
impingement

Posterior wall sign
•Posterior wall sign – pincer type FAI
•PW line should descend through center of femoral head
•Medial – deficient
•Lateral – prominent

In case of a deficient
posterior acetabular
wall, its outline is
visible medial to the
femoral head center.
Conversely, in case of
a prominent posterior
acetabular wall, its
outline can be seen
lateral to the femoral
head center.

Linear indentation sign
•Linear indentation sign – pincer type FAI
•Occurs due to mechanical injury and reactive change

Os acetabuli
•Associated with pincer type
•Os acetabuli

Cam type FAI
•Cam type of FAI
•Young males (32 years)
•Primary femoral abnormality
•Aspherical femoral head
•Femoral head jams into acetabular rim
•Shear forces on labrum and cartilage
•Diffuse articular damage
•Primary radiographic signs
 Pistol grip deformity
 CCD angle less than 125 degrees
 Horizontal growth plate sign
 Alpha angle greater than 50 degrees
 Femoral head-neck offset less than 8 mm
 Femoral retrotorsion

Pistol grip deformity
 Pistol grip deformity - Cam type FAI
•Loss of normal concavity
•Etiology
•Growth abnormality of the capital femoral epiphysis
•SCFE
•LCPD
•Fracture healing

 ’pistol -grip’’ deformity

Horizontal growth plate sign
•Horizontal growth plate sign - Cam type FAI

Alpha angle
•Alpha angle – Cam type FAI
•Used as an objective representation of the prominence of the anterior femoral head-neck junction.
•Abnormal is greater than 50 degrees
Normal Abnormal

Femoral head-neck offset
•Femoral head-neck offset (OS) – Cam type FAI
•Abnormal if less than 10 mm

Femoral retroversion
•Femoral retroverion – Cam type FAI
•Congenital or post traumatic
•Calc by CT
•Normal torsion
•Retrotorsion

Coxa vara
•Coxa vara - Cam type FAI
•Abnormally located femoral neck
•Decreased caput-collum-diaphyseal (CCD) angle
•Normal is 125 to 135

•Secondary radiographic signs
•Labral ossification
•Bony impaction changes
•Synovial herniation pits
•Premature degenerative changes

•Secondary MR findings in cam FAI
•Superolateral changes

•Classic MR findings in pincer FAI
•Posteroinferior cartilage abnormality due to contracoup injury

CT : more efficent for bone structures
, free intra –articular loose bodies

MRI & MRA
MRI :more efficient for soft tissue
structures, labrum, acetabular rim
MRA :isnow becoming the standard
investigation of F.A.I.
 ruptures of thelabrum
 abnormality of the head –neck junction
 ossification of thelabrum
 measurement of the α (alfa) angle

Differential diagnosis
 inguinal hernia
 low backdisorders
 trochanteric bursitis
 hip instability
 iliopsoas pathology
 Ischiofemoral impingement
 adductor strains and athletic pubalgia
 lumbar radiculopathy

TREATMENTS

NON-SURGICAL
NSAIDs
Cortisone
Physiotherapy
Massage
Root cause?
the fundamental reason for the occurrence
of a problem

Conservative Treatment
Theaim isto improve the symptoms
 Rest , modification ofactivities
 Avoid excessive motionactivities
 NSAIDS
 Intensive physiotherapy might aggravate the
condition trying to improve hip movement
 usually temporary relief of symptoms with
conservative treatment

 SURGICAL
The aim is to correct the cause of F.A.I. ,
improve hip motion
 Treatment
 Intertrochanteric flexion-valgus osteotomy
 Arthroscopic debridement
 Remove any nonspherical portion of femoral head
 Reduce size of acetabular rim in pincer type
 Periacetabular osteotomy
 Total arthroplasy in end stage disease
 Joint Reshaping
 Labral Repair
 Cartilage Regrowth
 Ligament Repair

Open surgery
• Lateral or posterolateralapproach
• Dislocation of the femoral head with care to
it’s bloodsupply
• Osteoplasty of the (‘’cam’’) head –neck
junction , with caution not to resect over
30% of the antero – lateral quadrant of the
neck. Risk of neck fracture
• Resection osteoplasty of the (‘’pincer’’)
acetabular rim , reorientation of the
acetabulum

Hip arthroscopy
Performed inlateral or supine position with
traction applied C –Arm imaging isessential for
safeentry of theportals
3portals :
1. Anterior
2. Anterolateral
3. Posterolateral

Hip arthroscopy
 Technically demanding
 Instrumentation dependent
 Care with patient selection
 Certain excellent indications
 Limited use in presence of existing
degeneration

 Debridement of
free loose bodies
Debridement of labral
and cartilage lesions
Microfractures
technique for the acetabular
cartilage
Correction ofthe acetabular
rimHead –neckjunction
osteoplasty

Alexander Brunner 2009

Open vs Arthroscopy :both havegood
results although patients operated with
arthroscopy recovered much earlier

•periacetabular osteotomy
•indications
•structural deformity of
acetabulum with significant
retroversion
•hip arthroplasty
•indications
•arthritic and end-stage hip
degeneration
•controversial regarding hip
resurfacing versus total hip
arthroplasty

POST-OPERATIVE
TREATMENT
Motor Control Strategies
Hip Weakness
Postural Misalignment

INITIAL REGIME
• IMPROVING ROM
• Light stretching CORE STABILISATION
• TrA, Pelvic Floor GLUTEAL ACTIVATION
• =Pelvic Floor Muscle and Transversus
Abdominis Activation .. Pelvic Pyramid, consists of the
transverse abdominis, multifidus, and pelvic floor muscles.

ADVANCED REGIME
FUNCTIONAL MOVEMENTS
Squats, Lunges STABILITY
EXERCISES
Wobble Boards, Dynadiscs
IMPACT EXERCISES
Hopping, Landing

REHABILITATION
 "Generally, motor control retraining is
more important than strength or power of
individual muscles."

Complications
 Femoral neck fracture
 at risk during femoroplasty
 risk is minimized by limiting depth of femoral
head-neck osteoplasty to <30% of femoral neck
diameter, using multiple fluoroscopy views of
femoral neck during procedure
 Heterotopic ossification
 Residual deformity following arthroscopic
treatment
 use of multiple fluoroscopy views

Conclusions
F.A.I. usually occurs in young to middle –
aged active adults and athletes
Can be a limitation to the level of activity
Conservative treatment improves the
symptoms but not thecause
Final solution could be the surgical treatment with
very good results

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‫د‬/‫قرنة‬ ‫بهاء‬

Femoroacetabular impingement (FAI)

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