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Diagnosis and Management of Femoroacetabular Impingement (FAI)

Diagnosis and Management of Femoroacetabular Impingement (FAI). Jason W. Folk, MD Steadman Hawkins Clinic of the Carolinas February 2012. Disclosures. Consultant Smith & Nephew Endoscopy. Femoroacetabular Impingement Outline. Background Pincer and Cam lesions Physical Exam findings

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Diagnosis and Management of Femoroacetabular Impingement (FAI)

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  1. Diagnosis and Management of Femoroacetabular Impingement (FAI) Jason W. Folk, MD Steadman Hawkins Clinic of the Carolinas February 2012

  2. Disclosures Consultant Smith & Nephew Endoscopy

  3. Femoroacetabular ImpingementOutline • Background • Pincer and Cam lesions • Physical Exam findings • Imaging • Open vs Arthroscopic tx

  4. Femoroacetabular Impingement • Abnormal dynamic contact between proximal femur and acetabulum that results in damage to femoral neck, acetabular rim, hip labrum, and articular cartilage.

  5. …in certain aberrant morphologic features of the hip, abnormal contact between the proximal femur and the acetabular rim that occurs during terminal motion of the hip, leads to lesions of the acetabular labrum and/or the adjacent acetabular cartilage.

  6. Femoroacetabular Impingement • Why do we talk about the labrum so much? • The first recognized pathologic consequence to deformity • Multiple biomechanical functions • Injury to labrum now recognized as a marker of significant underlying pathology

  7. Labral Function • Seals pressurized fluid layer within joint • Lubricates, prevents direct cartilage contact • Slows rate of fluid expression from porous cartilage layers • Limits cartilage deformation and stress

  8. Labral Function • Provides mechanical stability • Substantial extension of acetabular rim • Contributes to load transmission

  9. Adult Hip Osteoarthritis • Up to 90% of Young patients that develop DJD of the Hip Have an underlying structural Problem Ganz et al, CORR 2008

  10. Adult Hip Osteoarthritis • Theory was Postulated over 40 years ago • Murray 1965 • Solomon et al 1973 • Harris 1983 • Mechanism was Missing • Ganz, Leunig et al. 1996

  11. Progression of Hip DiseaseFAI 1986 28 yo Pistol Grip deformity: Stulberg SD 1975

  12. Progression of Hip DiseaseFAI 1994 1986

  13. Progression of Hip DiseaseFAI 1994 2007 47 yo 1986

  14. Prevalence of FAI 10-15%Anterior hip pain (C-sign)Pain: Protracted sitting With ambulation & catching arising from seatDifficulty: In and out of car Don/doff shoes and socks Hip Pain: Patient Assessment

  15. Physical Exam

  16. Clinical tests Posterior Impingement Anterior impingement Leunig M et al. Operat Tech Orthop, 15:247, 2005.

  17. Clinical tests The impingement test is performed with the hip in 90° of flexion with additional internal rotation and adduction of the femur.

  18. Two Types: Pincer and Cam Classification

  19. Pincer Type

  20. Impingement caused by retroversion of the acetabulum Primarily labral pathology Secondarily develop articular breakdown M:F 1:3 Avg age 40 (40-57) Pincer Type

  21. contre-coup

  22. contre-coup

  23. Anterior Wall Posterior Wall 1/2 1/3 Imaging: Physiologic Anteversion

  24. Cross over sign Imaging: Acetabular Retroversion

  25. Retroverted Acetabulum/ Crossover Sign

  26. Retroversion CT – axial cuts normal anteversion retroverted Reynolds D J Bone Joint Surg 81-B: 281-288; 1999.

  27. Cam type

  28. Impingement from bony prominence of anterolateral femoral head/neck junction Selective articular delamination (relative labral preservation) M:F 14:1 Avg age 32 (21-51) Cam type

  29. Cartilage labral delamination

  30. Imaging

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