Review Question - QID 219884

This patient presents with history, physical, and radiographic evidence of femoroacetabular impingement (FAI). In minimally symptomatic patients with no mechanical symptoms, the initial management is nonoperative modalities.

FAI is the abnormal contact between the femur and acetabulum with progressive hip pain. There are 3 general categories: cam impingement (femoral-based), pincer impingement (acetabular-based), or combined cam/pincer impingement. This abnormal contact results in decreased hip flexion and internal rotation and can progress to labral and chondral injury. For patients who failed nonoperative management, both arthroscopic and open techniques can be used to address the underlying bone deformity and the secondary labral injury. Although there is some controversy regarding optimal treatment strategies, nonoperative management is indicated in minimally symptomatic patients with no mechanical symptoms.

Gao et al published a review article on the nonsurgical versus surgical management of FAI. Several prospective studies have been completed which showed successful nonsurgical treatment, with notable improvement in 82-89% of patients. The authors review several level 1 studies that have compared operative management to physical therapy. They conclude that the highest level of evidence confirms that patients who undergo surgical management of FAI have higher International Hip Outcome Tool scores when compared to physical therapy alone.

Hunter et al published results from a multicenter randomized controlled trial comparing arthroscopic hip surgery to physical therapist-led care for FAI. The authors' primary outcome of hip cartilage metabolism, as measured by a delayed gadolinium-enhanced MRI of cartilage, showed no difference between the 2 groups. The secondary outcome of Hip Related Quality of Life score was higher in the operative cohort. The authors conclude that the reported benefit in symptoms at 12 months when comparing the 2 treatment groups is not explained by better hip cartilage metabolism.

Figure A shows an AP pelvis with bilateral cam deformity at the femoral head and neck. There is also borderline acetabular over coverage on the right. Figure B shows a false profile view of the right hip with a cam deformity. Os acetabuli (the small ossicles adjacent to the acetabular roof) can also be visualized in this view.

Incorrect Answers:
Answer 1: A bone scan is typically ordered for a femoral neck stress fracture in a patient who cannot undergo an MRI. It is not indicated in the diagnostic workup of FAI.
Answer 3,4,5: This patient should trial nonoperative modalities before undergoing surgical intervention.