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Femoro acetabular impingement syndrome

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Femoro acetabular impingement syndrome

  1. 1. FEMORO-ACETABULARFEMORO-ACETABULAR IMPINGEMENT SYNDROMEIMPINGEMENT SYNDROME JAYANT SHARMAJAYANT SHARMA M.S,D.N.B.,M.N.A.M.S.M.S,D.N.B.,M.N.A.M.S.
  2. 2. DEFINITIONDEFINITION It is a condition of too much friction in theIt is a condition of too much friction in the hip joint. Basically, the femoral head andhip joint. Basically, the femoral head and acetabulum rub abnormally creatingacetabulum rub abnormally creating damage to the hip joint. The damage candamage to the hip joint. The damage can occur to the articular cartilage or the labraloccur to the articular cartilage or the labral cartilage.cartilage.
  3. 3. Activities CAUSING FAIActivities CAUSING FAI Ice HockeyIce Hockey Horseback RidingHorseback Riding YogaYoga Football (American)Football (American) SoccerSoccer Ballet/Dance/AcrobaticsBallet/Dance/Acrobatics GolfGolf TennisTennis BaseballBaseball Field HockeyField Hockey RugbyRugby Bike Riding/CyclingBike Riding/Cycling Martial ArtsMartial Arts Deep squatting activities such as power liftingDeep squatting activities such as power lifting
  4. 4. EtiologyEtiology Significant athletic activity before skeletalSignificant athletic activity before skeletal maturity increases the risk of FAI.maturity increases the risk of FAI. Prior Biomechanical theories suggest thatPrior Biomechanical theories suggest that cartilage damage is initiated by Concentric orcartilage damage is initiated by Concentric or Eccentric overload.Eccentric overload. - Eccentric overload- Eccentric overload - easily explained by- easily explained by non-congruent articulations caused bynon-congruent articulations caused by developmental dysplasias and post-traumaticdevelopmental dysplasias and post-traumatic anatomyanatomy - Concentric overload- Concentric overload - not as easy to explain- not as easy to explain
  5. 5. Ganz et al. CORR. 2003Ganz et al. CORR. 2003 -- Summarized the concept of FAISummarized the concept of FAI - Mechanism for development of- Mechanism for development of osteoarthritis based on subtle aberrant bony morphologyosteoarthritis based on subtle aberrant bony morphology -- Acetabular Retroversion / CoxaAcetabular Retroversion / Coxa ProfundaProfunda -- Femoral Head non-sphericityFemoral Head non-sphericity -- Abnormal ContactAbnormal Contact in Normal / Nearin Normal / Near Normal Appearing HipsNormal Appearing Hips -- Abutment of the Proximal FemurAbutment of the Proximal Femur on the Acetabular Rim during terminal motion of the hipon the Acetabular Rim during terminal motion of the hip leading to lesions of the labrum and/or the adjacentleading to lesions of the labrum and/or the adjacent cartilagecartilage -- Chondral and Labral lesionsChondral and Labral lesions progressprogress and result in degenerative diseaseand result in degenerative disease
  6. 6. FAI FormsFAI Forms Generally occurs as two Cam and Pincer.Generally occurs as two Cam and Pincer. TheThe Cam formCam form (Cam comes from the(Cam comes from the Dutch word meaning “cog”) describes theDutch word meaning “cog”) describes the femoral head and neck relationship asfemoral head and neck relationship as aspherical.aspherical. This loss of roundness contributes toThis loss of roundness contributes to abnormal contact between the head andabnormal contact between the head and socket.socket.
  7. 7. CAM ImpingementCAM Impingement -- AnatomyAnatomy - Abnormal Femoral Head/Neck- Abnormal Femoral Head/Neck junction with increased radius at the waistjunction with increased radius at the waist - Motion- Motion - Impingement occurs primarily during- Impingement occurs primarily during flexion, adduction, IRflexion, adduction, IR -- MechanicsMechanics - Contact between the femoral neck- Contact between the femoral neck and acetabular rim induces compressionand acetabular rim induces compression - Shear stress generated at the junction- Shear stress generated at the junction between the labrum and the cartilage and at thebetween the labrum and the cartilage and at the subchondral tidemarksubchondral tidemark - Outward avulsion of the labrum- Outward avulsion of the labrum and/or an inward compression of the articular cartilageand/or an inward compression of the articular cartilage at Anterosuperior Rimat Anterosuperior Rim --
  8. 8. Etiology of CAM ImpingementEtiology of CAM Impingement - Elliptical Femoral Head- Elliptical Femoral Head - Slipped Capital Femoral- Slipped Capital Femoral Epiphysis -Epiphysis - SCFESCFE -- Legg Calve PerthesLegg Calve Perthes -- Adult OsteonecrosisAdult Osteonecrosis - Malunited Femoral Neck- Malunited Femoral Neck FracturesFractures
  9. 9. The Pincer FormThe Pincer Form Pincer comes from the French word meaning “toPincer comes from the French word meaning “to pinch”pinch” describes the situation where the socket ordescribes the situation where the socket or acetabulum has too much coverage of femoralacetabulum has too much coverage of femoral head.head. This over-coverage typically exists along theThis over-coverage typically exists along the front-top rim of the acetabulum,front-top rim of the acetabulum, results in the labral cartilage being “pinched”results in the labral cartilage being “pinched” between the rim and the anterior femoral head-between the rim and the anterior femoral head- neck junction.neck junction.
  10. 10. Pincer form of the ImpingementPincer form of the Impingement Secondary to “retroversion”, or “profunda”,Secondary to “retroversion”, or “profunda”, Most of the time, the Cam and PincerMost of the time, the Cam and Pincer forms exist together.forms exist together.
  11. 11. Pincer ImpingementPincer Impingement -- AnatomyAnatomy - Excessive Acetabular Coverage- Excessive Acetabular Coverage - Motion- Motion - Dependent on acetabular morphology- Dependent on acetabular morphology -- MechanicsMechanics - Linear Contact between the labrum and femoral- Linear Contact between the labrum and femoral head/neck junctionhead/neck junction - Anterior = Acetabular Retroversion- Anterior = Acetabular Retroversion - Circumferential = Coxa Profunda- Circumferential = Coxa Profunda - Force from the femoral neck is transferred through the- Force from the femoral neck is transferred through the labrum to the acetabular cartilagelabrum to the acetabular cartilage Results is chronic degeneration ofResults is chronic degeneration of anterior labrum and subsequent ossificationanterior labrum and subsequent ossification Further deepens theFurther deepens the cup.cup. Resultant leverage of head in acetabulum with excessiveResultant leverage of head in acetabulum with excessive ROM can result in contre-coup lesion in posteroinferior acetabulumROM can result in contre-coup lesion in posteroinferior acetabulum and posteromedial femoral headand posteromedial femoral head - Leading to Circumferential involvement- Leading to Circumferential involvement
  12. 12. EtiologyEtiology - Acetabular Retroversion- Acetabular Retroversion - Coxa Profunda- Coxa Profunda - Protrusio Acetabuli- Protrusio Acetabuli - Iatrogenic- Iatrogenic overcorrection forovercorrection for retroversion/dysplasiaretroversion/dysplasia - Coxa Vara- Coxa Vara - Os Acetabuli- Os Acetabuli
  13. 13. ASSOCIATED CARTILAGEASSOCIATED CARTILAGE FAI is associated with cartilage damage,FAI is associated with cartilage damage, labral tears,labral tears, early hip arthritis,early hip arthritis, hyperlaxity,hyperlaxity, sports hernias, andsports hernias, and low back pain.low back pain. FAI is common in high level athletes, butFAI is common in high level athletes, but also occurs in active individualsalso occurs in active individuals
  14. 14. DiagnosisDiagnosis Most patients can be diagnosed with aMost patients can be diagnosed with a good history,good history, AA patient’s historypatient’s history .. TheThe physical examphysical exam TheThe plain x-rayplain x-ray filmsfilms
  15. 15. EXAMINATIONEXAMINATION Gait should be closely scrutinized looking forGait should be closely scrutinized looking for an abductor lurch,an abductor lurch, a shortened stance phase,a shortened stance phase, circumduction, or steppage.circumduction, or steppage. Leg lengths should be measured using accurateLeg lengths should be measured using accurate methods.methods. The patient's posture should be noted, includingThe patient's posture should be noted, including examination of the back for scoliosis.examination of the back for scoliosis.
  16. 16. Anterior femoral-acetabularAnterior femoral-acetabular impingementimpingement the affected hip is flexed to ninty degrees and the leg isthe affected hip is flexed to ninty degrees and the leg is internally rotated and adducted.internally rotated and adducted. If there is abnormal contact between the anterior-If there is abnormal contact between the anterior- superior acetabular rim and femoral neck, pain may besuperior acetabular rim and femoral neck, pain may be elicited.elicited. Posterior impingement may be tested by having thePosterior impingement may be tested by having the patient dangle their legs off the end of an examinationpatient dangle their legs off the end of an examination table,table, with the affected leg externally rotated by the examiner,with the affected leg externally rotated by the examiner, and the opposite limb held flexed by the patient. In aand the opposite limb held flexed by the patient. In a positive exam, the femur contacts the posteriorpositive exam, the femur contacts the posterior acetabular rim eliciting pain.acetabular rim eliciting pain.
  17. 17. EXAMINATIONEXAMINATION The range of motionThe range of motion A decreased range of motion of the hip,A decreased range of motion of the hip, especially in cases of an external rotationespecially in cases of an external rotation contracture, can point to an intra-articular causecontracture, can point to an intra-articular cause of the pain.of the pain. Patients with hip pathology often also develop aPatients with hip pathology often also develop a flexion contracture. The Thomas test is a helpfulflexion contracture. The Thomas test is a helpful maneuver.maneuver. A thorough neurovascular exam should beA thorough neurovascular exam should be conducted to rule out spine and other neuralconducted to rule out spine and other neural causes of the patient's pain.causes of the patient's pain.
  18. 18. RADIOLOGYRADIOLOGY The AP pelvis X-ray must be well centeredThe AP pelvis X-ray must be well centered and well developed as to show a clearand well developed as to show a clear outline of the acetabulum.outline of the acetabulum. The coccyx should point toward theThe coccyx should point toward the symphysis pubis, and there should besymphysis pubis, and there should be about 1-2 cm between them.about 1-2 cm between them. The anterior and posterior walls, the tearThe anterior and posterior walls, the tear drop and the lateral edge of thedrop and the lateral edge of the acetabulum should be noted.acetabulum should be noted.
  19. 19. MeasurementsMeasurements may be taken to evaluate for hip dysplasiamay be taken to evaluate for hip dysplasia including theincluding the Tönnis angleTönnis angle (abnormal < 10(abnormal < 10 degrees),degrees), the lateral center-edge angle of Wibergthe lateral center-edge angle of Wiberg (abnormal < 25 degrees), and(abnormal < 25 degrees), and thethe Anterior center-edge angle of LequesneAnterior center-edge angle of Lequesne (abnormal < 25 degrees) as measured on a(abnormal < 25 degrees) as measured on a false-profile radiograph.false-profile radiograph. The neck shaft angleThe neck shaft angle of the proximal femur isof the proximal femur is considered normal between 120 and 140considered normal between 120 and 140 degrees.degrees.
  20. 20. Coxa ProfundaCoxa Profunda When the floor of the acetabular fossa is inWhen the floor of the acetabular fossa is in line with the ilioischial line;line with the ilioischial line; Protrusio is present when the medial mostProtrusio is present when the medial most femoral head overlaps the ilioischial line.femoral head overlaps the ilioischial line. The crossover signThe crossover sign is a sensitive and specificis a sensitive and specific indicator of native acetabular version.indicator of native acetabular version. On anOn an AP pelvis radiographAP pelvis radiograph, the outlines of, the outlines of the edges of the anterior and posterior wallsthe edges of the anterior and posterior walls of the acetabulum should meet superiorlyof the acetabulum should meet superiorly and laterally.and laterally.
  21. 21. COXA PROFUNDACOXA PROFUNDA In cases ofIn cases of acetabular retroversionacetabular retroversion, this, this crossover of the anterior and posteriorcrossover of the anterior and posterior acetabular wall outlines is more distal.acetabular wall outlines is more distal. Changes in the acetabular rim may alsoChanges in the acetabular rim may also be noted.be noted. AA 'double line'double line' is seen in labral' is seen in labral ossification.ossification. AnAn os acetabulios acetabuli may also be an indicatormay also be an indicator of pathologyof pathology
  22. 22. Alterations of the proximal femoral anatomy, such asAlterations of the proximal femoral anatomy, such as head neck offset and bump formation can be observed inhead neck offset and bump formation can be observed in addition to acetabular and labral pathology.addition to acetabular and labral pathology. A pistol grip deformity of the femoral head is often seenA pistol grip deformity of the femoral head is often seen in Cam Type impingement.in Cam Type impingement. In this situation the superior-lateral head neck junction isIn this situation the superior-lateral head neck junction is convex instead of concave.convex instead of concave. A high fovea can also indicate asphericity of the femoralA high fovea can also indicate asphericity of the femoral head that is not able to be appreciated on the AP films.head that is not able to be appreciated on the AP films. A cross table lateral may show an abnormality in theA cross table lateral may show an abnormality in the anterior head neck junction in cases of impingement.anterior head neck junction in cases of impingement.
  23. 23. The Alpha AngleThe Alpha Angle Drawn on the AP pelvis radiograph, is formedDrawn on the AP pelvis radiograph, is formed by a line drawn from the center of the femoralby a line drawn from the center of the femoral head through the center of the femoral neck,head through the center of the femoral neck, A line from the center of the femoral head toA line from the center of the femoral head to the femoral head/neck junction, found by thethe femoral head/neck junction, found by the point by which the femoral neck diverges from apoint by which the femoral neck diverges from a circle drawn around the femoral head.circle drawn around the femoral head. A normal patients' alpha angle is around 45A normal patients' alpha angle is around 45 degrees,degrees, whereas patients withwhereas patients with FemoroacetabularFemoroacetabular impingement may be around 70 degrees.impingement may be around 70 degrees.
  24. 24. ALPHA ANGLEALPHA ANGLE
  25. 25. TONNIS ANGLE
  26. 26. LCA CROSS OVER
  27. 27. PROFUNDA ACEA
  28. 28. MRIMRI Often an MRI of the hip is used to confirmOften an MRI of the hip is used to confirm a labral tear or damage to the jointa labral tear or damage to the joint surface.surface. The MRI is most helpful in eliminatingThe MRI is most helpful in eliminating certain causes of non FAI hip paincertain causes of non FAI hip pain including avascular necrosis (dead bone)including avascular necrosis (dead bone) and tumors.and tumors.
  29. 29. DIFFRENTIAL DIAGNOSISDIFFRENTIAL DIAGNOSIS Hip Dysplasia (Adult Form)Hip Dysplasia (Adult Form) Lumbar Spine Pain (Low Back Pain)Lumbar Spine Pain (Low Back Pain) Lumbar Radiculopathy Low Back Facet Disease)Lumbar Radiculopathy Low Back Facet Disease) SacroiliitisSacroiliitis Trochanteric BursitisTrochanteric Bursitis Piriformis SyndromePiriformis Syndrome Psychosomatic Pain DisorderPsychosomatic Pain Disorder Iliopsoas Tendinitis/Tendonitis/TendinosisIliopsoas Tendinitis/Tendonitis/Tendinosis Groin PullGroin Pull Sports Hernia (abdominal muscle strain)Sports Hernia (abdominal muscle strain) Iliac ApophysitisIliac Apophysitis Quadriceps Hernia/Strain Chronic Pain SyndromesQuadriceps Hernia/Strain Chronic Pain Syndromes
  30. 30. TreatmentTreatment Non-operativeNon-operative A course of non-operative treatment forA course of non-operative treatment for most hip pathology may be tried first.most hip pathology may be tried first. Patients presenting with femoroacetabularPatients presenting with femoroacetabular impingement or labral disease may tryimpingement or labral disease may try modification of activitymodification of activity avoiding excessive hip movementavoiding excessive hip movement regular non-steroidal anti-inflammatoryregular non-steroidal anti-inflammatory medicationmedication
  31. 31. ArthroscopyArthroscopy Arthroscopic assessment of the hip can includeArthroscopic assessment of the hip can include examination of both the central and peripheralexamination of both the central and peripheral compartments.compartments. The central compartment includes the labrum and allThe central compartment includes the labrum and all structures located further medially.structures located further medially. Tearing of the labrum anterolaterally and damage to theTearing of the labrum anterolaterally and damage to the acetabular cartilage is characteristic.acetabular cartilage is characteristic. The lesions of the labrum and any areas of chondralThe lesions of the labrum and any areas of chondral damage are debrided.damage are debrided. Labral repair may be possible for specific tears.Labral repair may be possible for specific tears. For areas of exposed subchondral bone a microfractureFor areas of exposed subchondral bone a microfracture technique may be performed.technique may be performed.
  32. 32. SAFE Surgical Hip Dislocation-SAFE Surgical Hip Dislocation- OsteoplastyOsteoplasty Surgical dislocation of the hip has been described.Surgical dislocation of the hip has been described. A posterior incision (Kocher-Langenbeck) as this approachA posterior incision (Kocher-Langenbeck) as this approach usually provides better access to posterior parts of the jointusually provides better access to posterior parts of the joint after the hip is dislocated.after the hip is dislocated. A trochanteric flip osteotomy is performed. The trochanter isA trochanteric flip osteotomy is performed. The trochanter is osteotomized from a posterior to anterior direction, the cutosteotomized from a posterior to anterior direction, the cut exits superficial to the piriformis fossa superiorly and at theexits superficial to the piriformis fossa superiorly and at the vastus ridge inferiorly.vastus ridge inferiorly. The gluteus minimus muscle is dissected carefully off theThe gluteus minimus muscle is dissected carefully off the capsule starting at the piriformis interval.capsule starting at the piriformis interval. The capsulotomy is Z-shaped (for the right hip), with theThe capsulotomy is Z-shaped (for the right hip), with the superior limb located along the posterior acetabular rim, andsuperior limb located along the posterior acetabular rim, and the inferior limb located at the level of the anteromedialthe inferior limb located at the level of the anteromedial femoral neckfemoral neck
  33. 33. After dislocation of the hip, the acetabular labrum andAfter dislocation of the hip, the acetabular labrum and the adjacent articular cartilage are assessed, and thethe adjacent articular cartilage are assessed, and the identified lesions are tested for partial or completeidentified lesions are tested for partial or complete avulsions from the acetabular rim.avulsions from the acetabular rim. The severity, extent, and location of these lesions shouldThe severity, extent, and location of these lesions should be defined, and their association with FAI should bebe defined, and their association with FAI should be confirmed by provocative maneuvers in flexion andconfirmed by provocative maneuvers in flexion and internal rotation with the head relocated.internal rotation with the head relocated. The combination of anterior over coverage and theThe combination of anterior over coverage and the status of the labrum and the acetabular articular cartilagestatus of the labrum and the acetabular articular cartilage will determine the type of treatment of the acetabularwill determine the type of treatment of the acetabular rim.rim. In cases of anterior over coverage contributing to FAI,In cases of anterior over coverage contributing to FAI, as is frequent with acetabular retroversion, a resectionas is frequent with acetabular retroversion, a resection osteoplasty of the anterosuperior rim is done.osteoplasty of the anterosuperior rim is done.
  34. 34. Periacetabular OsteotomyPeriacetabular Osteotomy Reorientation of the articulating surfaces of theReorientation of the articulating surfaces of the hip joint is an attractive procedure in the patienthip joint is an attractive procedure in the patient with hip dysplasia.with hip dysplasia. Increased joint congruity after reorientation ofIncreased joint congruity after reorientation of the osteotomized fragment allows loadthe osteotomized fragment allows load transmission through a broader area subjectedtransmission through a broader area subjected to less pressure.to less pressure. These changes can be expected to reduce painThese changes can be expected to reduce pain and possibly protect the articular cartilage fromand possibly protect the articular cartilage from degenerative changesdegenerative changes
  35. 35. Pelvic OsteotomyPelvic Osteotomy Corrects the major anatomic abnormalityCorrects the major anatomic abnormality and has the further advantage overand has the further advantage over femoral osteotomy of not creating afemoral osteotomy of not creating a secondary femoral deformity.secondary femoral deformity. Femoral osteotomy may be added toFemoral osteotomy may be added to pelvic osteotomy when coexistent femoralpelvic osteotomy when coexistent femoral anatomic abnormalities are significant.anatomic abnormalities are significant.
  36. 36. Bernese Periacetabular OsteotomyBernese Periacetabular Osteotomy The is indicated for patients with hipThe is indicated for patients with hip symptoms of mechanical overload,symptoms of mechanical overload, impingement, or hip instability as a resultimpingement, or hip instability as a result of insufficient acetabular coverage.of insufficient acetabular coverage.

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