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Femoroacetabular impingement (FAI)

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Femoroacetabular impingement (FAI)

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painful hip in adults active person either male or female. limitation in hip movement, In FAI, bone overgrowth — called bone spurs — develop around the femoral head and/or along the acetabulum.

painful hip in adults active person either male or female. limitation in hip movement, In FAI, bone overgrowth — called bone spurs — develop around the femoral head and/or along the acetabulum.

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Femoroacetabular impingement (FAI)

  1. 1. Femoroacetabular Impingement (FAI) Bahaa' Ali Kornah • Professor of Orthopedic Surgery • Faculty of Medicine • Al Azhar university bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  2. 2. 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
  3. 3. 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 bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  4. 4. 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) bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  5. 5. 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 bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  6. 6. Pathoanatomic  Types  Cam (femoral based disorder )  Pincer (Acetabular based disorder )  Mixed  (Lavigne et al.,2004) bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  7. 7. 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 bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  8. 8. 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) bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  9. 9. •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 bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  10. 10. ‘’cam’’ type :  non spherical head  reduce of head –neck offset  widening of head –neck junction  ’pistol –grip’’ deformity ‘ bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  11. 11. ‘’Cam’’ type : damage to the antero – superior area of the acetabulum (1 o’clock) M : F – 14 : 1 bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  12. 12. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  13. 13. 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 bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  14. 14. 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) bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  15. 15. ‘’pincer type’’ : 1. Excessive acetabular cover (coxa profunda) 2. acetabular retroversion 3. Protrusio acetabuli bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  16. 16. 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 bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  17. 17. •Combined Cam/Pincer impingement •can include both patient populations •refers to combinations of above (up to 80%) •SCFE deformity causes variable patterns of impingement bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  18. 18. 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
  19. 19. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  20. 20. PREDISPOSING FACTORS  YOUNG  ...often ACTIVE  ...usually MALE  ...mostly bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  21. 21. •  •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
  22. 22. -Proposed etiologies 1. Abnormal hip morphology (Abnormal anatomy ) 2. Normal hip morphology but excessive range of hip movement bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  23. 23. 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) bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  24. 24. ACTIVITIES Football,Dancing ,MartialArts bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  25. 25. MEANING... ** Large Hip ROM ** Axial Loading of Hip ** Torsional Forces bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  26. 26. physiologie articulaire kapandji I.A. Kapandji bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  27. 27. Hip Anatomy Polyaxial ‘ball & socket’ synovial joint Stability v Mobility  Labrum  Ligaments  Iliofemoral / Pubofemoral / Ischiofemoral  Neck-shaft 125-135°  FNA 8-15° bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  28. 28. 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 bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  29. 29. 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 bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  30. 30. Diagnosis & Differential Diagnosis bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  31. 31. 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 bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  32. 32. 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 bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  33. 33. Femoro-acetabular impingement Clinical assessment Anterior FAI  Pain in Flexion,Adduction and IR Posterior FAI  Pain in Extension, External rotation
  34. 34. SYMPTOMS bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  35. 35. WALKING PATTERNS bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  36. 36. ANTALGIC GAIT bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  37. 37. TRENDELENBURG GAIT bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  38. 38. POSITIVE IMPINGEMENT TEST 90%ofFAIsuffererstestpositive bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  39. 39. FALSE POSITIVES (OTHER POSSIBLE CAUSES) • Hip dysplasia Avascular necrosis • Slipped Capital Femoral Epiphysis • Legg-Calvé-Perthes Disease bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  40. 40. Special tests Tests for impingement bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  41. 41. 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 bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  42. 42. Tests to assess impingement  Scour test  Patient position- Supine  Procedure- Done by moving the hip in an arc bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  43. 43. Tests to assess impingement  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. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  44. 44. Tests to assess impingement  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. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  45. 45. 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. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  46. 46. Tests to assess impingement  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. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  47. 47. XRAY MRI MRA CT SCAN bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  48. 48. Imaging :  AP with true lateral view (hip placed in 15 degrees of internal rotation)  ’pistol -grip’’ deformity  non spherical head  free intra–articular bodies ‘ bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  49. 49. 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 bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  50. 50. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  51. 51. Coxa Profunda •Coxa profunda – floor of fossa acetabuli overlaps ilioischial line medially •Pincer type FAI •Creates deep acetabulum •General overcoverage •Normal bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  52. 52. Protrusio acetabuli •Protrusio acetabuli – occurs when the femoral head overlaps the ilioischial line medially •Pincer type FAI •Creates deep acetabulum •General overcoverage •Normal bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  53. 53. 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 bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  54. 54. Decreased extrusion index •Decreased extrusion index – pincer type FAI •(E / [A + E]) •25 % in normal subjects •Decreases as femoral head becomes “more covered.” bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  55. 55. Acetabular index •Acetabular index – pincer type FAI •Should be positive •Becomes negative as acetabulum “deepens” Positive AI Negative AI in protrusio acetabuli bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  56. 56. 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 bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  57. 57. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT •crossover sign •indicates acetabular retroversion in Pincer impingement
  58. 58. Posterior wall sign •Posterior wall sign – pincer type FAI •PW line should descend through center of femoral head •Medial – deficient •Lateral – prominent bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  59. 59. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT 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.
  60. 60. Linear indentation sign •Linear indentation sign – pincer type FAI •Occurs due to mechanical injury and reactive change bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  61. 61. Os acetabuli •Associated with pincer type •Os acetabuli bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  62. 62. 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 bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  63. 63. 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 bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  64. 64.  ’pistol -grip’’ deformity bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  65. 65. Horizontal growth plate sign •Horizontal growth plate sign - Cam type FAI bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  66. 66. 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 bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  67. 67. Femoral head-neck offset •Femoral head-neck offset (OS) – Cam type FAI •Abnormal if less than 10 mm bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  68. 68. Femoral retroversion •Femoral retroverion – Cam type FAI •Congenital or post traumatic •Calc by CT •Normal torsion •Retrotorsion bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  69. 69. Coxa vara •Coxa vara - Cam type FAI •Abnormally located femoral neck •Decreased caput-collum-diaphyseal (CCD) angle •Normal is 125 to 135 bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  70. 70. •Secondary radiographic signs •Labral ossification •Bony impaction changes •Synovial herniation pits •Premature degenerative changes bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  71. 71. •Secondary MR findings in cam FAI •Superolateral changes bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  72. 72. •Classic MR findings in pincer FAI •Posteroinferior cartilage abnormality due to contracoup injury bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  73. 73. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  74. 74. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  75. 75. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  76. 76. CT : more efficent for bone structures , free intra –articular loose bodies bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  77. 77. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  78. 78. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  79. 79. 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 bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  80. 80. Differential diagnosis  inguinal hernia  low backdisorders  trochanteric bursitis  hip instability  iliopsoas pathology  Ischiofemoral impingement  adductor strains and athletic pubalgia  lumbar radiculopathy bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  81. 81. TREATMENTS bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  82. 82. NON-SURGICAL NSAIDs Cortisone Physiotherapy Massage Root cause? bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT the fundamental reason for the occurrence of a problem
  83. 83. 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 bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  84. 84.  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 bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  85. 85. 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 bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  86. 86. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  87. 87. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  88. 88. 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 bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  89. 89. Hip arthroscopy  Technically demanding  Instrumentation dependent  Care with patient selection  Certain excellent indications  Limited use in presence of existing degeneration bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  90. 90.  Debridement of free loose bodies Debridement of labral and cartilage lesions Microfractures technique for the acetabular cartilage Correction ofthe acetabular rimHead –neckjunction osteoplasty bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  91. 91. Alexander Brunner 2009 bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  92. 92. Open vs Arthroscopy :both havegood results although patients operated with arthroscopy recovered much earlier bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  93. 93. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT •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
  94. 94. POST-OPERATIVE TREATMENT Motor Control Strategies Hip Weakness Postural Misalignment bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  95. 95. 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. bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  96. 96. ADVANCED REGIME FUNCTIONAL MOVEMENTS Squats, Lunges STABILITY EXERCISES Wobble Boards, Dynadiscs IMPACT EXERCISES Hopping, Landing bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  97. 97. REHABILITATION  "Generally, motor control retraining is more important than strength or power of individual muscles." bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  98. 98. 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 bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  99. 99. 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 bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT
  100. 100. ‫ا‬.‫د‬.‫قرنة‬ ‫بهاء‬ ‫د‬/‫قرنة‬ ‫بهاء‬ bahaa Ali Kornah-Al-Azhar Un. Cairo -EGYPT

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