Introduction Overview abnormal contact between the femur and acetabulum which leads to labral damage and various degrees of chondral injury Epidemiology femoral and acetabular deformity common in general population and often asymptomatic may become more apparent with participation in activities requiring extreme range of motion (ballet, gymnastics, martial arts) Pathophysiology mechanism of injury proximal femur abuts acetabulum with range of motion, especially during flexion pathoanatomy Cam impingement refers to femoral based disorder usually in young athletic males occurs if femoral head/neck bone is too broad, mostly on the anterolateral neck 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 Pincer impingement refers to acetabular based disorder usually in active middle-aged women occurs if acetabular bone/labrum overhang is too broad, mostly at the anterosuperior quadrant anterosuperior acetabular rim overcoverage acetabular retroversion acetabular protrusio coxa profunda the femoral neck impinges and crushes the labrum creating intra-substance tearing this levers the femoral head into the postero-inferior acetabulum leading to a contrecoup cartilaginous injury combined Cam/Pincer impingement can include both patient populations refers to combinations of above (up to 80%) SCFE deformity causes variable patterns of impingement Associated injuries labral degeneration and tears cartilage damage and flap tears secondary hip osteoarthritis Prognosis natural history believed to lead to early onset hip dysfunction and arthritis Anatomy Osteology highly congruous joint formed by Acetabulum formed by confluence of ischium, ilium and pubic bones Femur spherical head on neck, anteverted 15 degrees in relation to femoral condyles Muscles 5 major muscle groups acting across hip hip flexors, extensors, abductors, adductors, and external rotators Capsule and Ligaments 3 ligaments of the form joint capsule iliofemoral ligament (Y ligament of Bigelow) ischiofemoral ligament pubofemoral ligament labrum horseshoe-shaped fibrocartilaginous tissue extending around periphery of acetabulum connected by transverse acetabular ligament at inferior acetabulum increases acetabular volume and provides suction seal ligamentum teres extends from cotyloid fossa to femoral head negligible contribution to vascular supply of femoral head in adult Presentation Symptoms common symptoms activity related groin or hip pain, exacerbated by hip flexion difficulty sitting mechanical hip symptoms of clicking or popping can present with gluteal or trochanteric pain due to aberrant gait mechanics Exam motion limited hip flexion (<90 degrees), especially with internal rotation (<5 degrees) anterior impingement test (flexion, adduction, internal rotation) elicits pain inspection externally rotated extremity can be due to post-SCFE deformity Imaging Radiographs recommended views AP with true lateral view (hip placed in 15 degrees of internal rotation) optional views Dunn or modified Dunn view false profile view to assess anterior coverage of the femoral head standing position at an angle of 65° between the pelvis and the film findings asphericity and contour of femoral head and neck pistol grip deformity indicates Cam impingement examine for acetabular protrusio, retroversion, and coxa profunda crossover sign indicates acetabular retroversion in Pincer impingement posterior wall sign measurements alpha angle method measured frog-leg lateral radiograph first line is drawn connecting the center of the femoral head and the center of the femoral neck. second line is drawn from the center of the femoral head to the point on the anterolateral head-neck junction where prominence begins the intersection of these two lines forms the alpha angle normal values values of >42° are suggestive of a head-neck offset deformity, >50-55° indicates Cam deformity head-neck offset ratio method measured from lateral radiographs a line #1 is drawn through the center of the long axis of the femoral neck line #2 is drawn parallel to line 1 through the anteriormost aspect of the femoral neck line #3 is drawn parallel to line 2 through the anteriormost aspect of the femoral head the head-neck offset ratio is calculated by measuring the distance between lines 2 and 3, and dividing by the diameter of the femoral head normal values If the ratio is <0.17, a cam deformity is likely present lateral center-edge angle (angle of Wiberg) normal value under 40 degrees anterior center-edge angle normal value over 20 degrees acetabular index or Tonnis roof angle normal value above 0 degrees CT can be used as adjunct to assess for structural abnormalities MRI and/or MR arthrogram best modality to evaluate for articular cartilage and labral damage can assess anatomy of femoral head/neck junction abnormalities Differential Various pathologies will refer pain to the hip region hip instability iliopsoas pathology adductor strains lumbar radiculopathy Treatment Nonoperative activity modification, PT, NSAIDs indications minimally symptomatic patient no mechanical symptoms modalities period of rest or activity modification followed by physical therapy to address kinetic chain abnormalities NSAIDs Operative arthroscopic osteoplasty indications symptomatic patient with mechanical symptoms failure of non-operative measures non-arthritic outcomes recent literature supports arthroscopy shows equivalent results to open hip surgery open surgical hip dislocation and osteoplasty indications previous gold standard for patients with clinical signs and structural evidence of impingement preserved articular cartilage, correctable deformity, reasonable expectations significant femoral deformity (residual SCFE or Perthes) 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 Techniques Arthroscopic osteoplasty approach arthroscopic approach to the hip soft tissue capsulotomy required to access peripheral component to address CAM labral repair/refixation required following acetabuloplasty if labrum is destabilized bony work trim femoral head/neck in Cam impingement acetabular rim trimming followed by labral debridement vs repair/reconstruction isolated labral debridement of labral tears will not provide long-term benefit without treatment of underlying bony pathology outcomes equivalent success compared to open procedure complications neurapraxias associated with hip arthroscopy Ganz open surgical hip dislocation and osteoplasty approach Kocher-Langenbeck incision while in lateral decubitus position, gluteus maximus split digastric "trochanteric flip" performed and fragment mobilized anteriorly capsulotomy performed, hip dislocated anteriorly, ligamentum teres likely transected allows safe access to proximal femur and acetabulum alternatively, a direct anterior approach may be utilized but grants limited visualization to posterior acetabulum bony work same as arthroscopic osteoplasty soft tissue labral repair/refixation/reconstruction required following acetabuloplasty if labrum is destabilized outcomes provides wide exposure of femoral head and acetabulum while preserving all external rotators and blood supply to femoral head (medial circumflex femoral artery) no increase in AVN risk median expected time to return to sports is 7 months in adolescent athletes complications trochanteric hip pain Combined arthroscopic and limited open approach combines aspects of both procedures to gain access to entire femur and acetabulum early results promising 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
QUESTIONS 1 of 21 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway (OBQ11.259) In the radiographic evaluation of femoroacetabular impingment (FAI), which of the following views is obtained with a standing radiograph and an angle of 65 degrees between the pelvis and the film? Review Topic QID: 3682 Type & Select Correct Answer 1 AP pelvis 2% (89/5289) 2 Inlet 5% (266/5289) 3 Outlet 3% (157/5289) 4 Frog lateral 5% (285/5289) 5 False profile 85% (4475/5289) L 1 Select Answer to see Preferred Response SUBMIT RESPONSE 5 Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway This is an AAOS Self assessment question. Orthobullets was not involved into the editorial process, and does not have the ability to alter. If you prefer to hide SAE questions on topics simply turn them off in your Content Settings (SAE07HK.44) Figure 24 shows the radiograph of a 36-year-old volleyball player with right hip pain. What is the cause of the pain? Review Topic QID: 6004 FIGURES: A Type & Select Correct Answer 1 Osteonecrosis 1% (2/218) 2 Rheumatoid arthritis 0% (1/218) 3 Developmental dysplasia of the acetabulum 3% (7/218) 4 Femoral neck fracture 0% (1/218) 5 Femoral acetabular impingement 94% (205/218) L 1 Select Answer to see Preferred Response SUBMIT RESPONSE 5 You have 100% on this question. Just skip this one for now. Take This Question Anyway This is an AAOS Self assessment question. Orthobullets was not involved into the editorial process, and does not have the ability to alter. If you prefer to hide SAE questions on topics simply turn them off in your Content Settings (SAE07HK.35) A patient reports pain in the hip with functional positioning. With the patient supine, pain in which of the following positions would be typical for femoral acetabular impingement? Review Topic QID: 5995 Type & Select Correct Answer 1 Hip is internally rotated, passively flexed to 90 degrees, and adducted 75% (156/209) 2 Hip is internally rotated, passively flexed to 90 degrees, and abducted 10% (20/209) 3 Hip is externally rotated, maximally flexed to 90 degrees, and adducted 2% (5/209) 4 Hip is externally rotated, passively flexed to 90 degrees, and abducted 11% (23/209) 5 Hip is externally rotated, maximally flexed, and abducted 1% (3/209) L 2 Select Answer to see Preferred Response SUBMIT RESPONSE 1
All Videos (22) Podcasts (3) Login to View Community Videos Login to View Community Videos 2018 Chicago Sports Medicine Symposium: World Series of Surgery Ischiofemoral Impingement - Allston J. Stubbs, MD (CSMS #99, 2018) Allston Stubbs Knee & Sports - Femoroacetabular Impingement 11/25/2018 284 views Login to View Community Videos Login to View Community Videos 2018 Chicago Sports Medicine Symposium: World Series of Surgery FAI, Labrum Case Presentations, Question and Answer - Moderator: Shane J. Nho, MD, MS (CSMS #96, 2018) Knee & Sports - Femoroacetabular Impingement 11/25/2018 150 views Login to View Community Videos Login to View Community Videos 2018 Chicago Sports Medicine Symposium: World Series of Surgery Subspine Impingement: Pearls and Pitfalls - Richard C. Mather, MD (CSMS #89, 2018) Richard Mather Knee & Sports - Femoroacetabular Impingement 11/25/2018 148 views Login to View Community Videos Login to View Community Videos 2018 Chicago Sports Medicine Symposium: World Series of Surgery Pincer Impingement: Diagnostic Imaging & Surgical Treatment - Michael Ellman, MD (CSMS #88, 2018) Michael Ellman Knee & Sports - Femoroacetabular Impingement 11/25/2018 207 views Login to View Community Videos Login to View Community Videos 2018 Chicago Sports Medicine Symposium: World Series of Surgery It’s All About the Correction of FAIS - Joshua Harris, MD (CSMS #87, 2018) Joshua Harris Knee & Sports - Femoroacetabular Impingement 11/25/2018 321 views Login to View Community Videos Login to View Community Videos 2018 Chicago Sports Medicine Symposium: World Series of Surgery FAIS Should Only Be Treated with Surgery - Allston J. Stubbs, MD (CSMS #85, 2018) Allston Stubbs Knee & Sports - Femoroacetabular Impingement 11/25/2018 133 views Login to View Community Videos Login to View Community Videos 2018 Chicago Sports Medicine Symposium: World Series of Surgery FAIS Can Be Treated Without Surgery - Bradley Allison, PT, DPT, OCS (CSMS #84, 2018) Knee & Sports - Femoroacetabular Impingement 11/25/2018 73 views Login to View Community Videos Login to View Community Videos 2017 HSS Holiday Knee & Hip Course Hip Preservation Considerations in the Athlete - Bryan T. Kelly, MD Knee & Sports - Femoroacetabular Impingement 8/30/2018 265 views Login to View Community Videos Login to View Community Videos 2017 Chicago Sports Medicine Symposium: World Series of Surgery Femoroacetabular Impingement: Case Based Panel Discussion (CSMS #89, 2017) Knee & Sports - Femoroacetabular Impingement 11/17/2017 183 views Login to View Community Videos Login to View Community Videos 2017 Chicago Sports Medicine Symposium: World Series of Surgery Indications for Open Management of FAI - Michael D. Stover, MD (CSMS #86, 2017) Michael Stover Knee & Sports - Femoroacetabular Impingement 11/17/2017 70 views Login to View Community Videos Login to View Community Videos 2017 Chicago Sports Medicine Symposium: World Series of Surgery Hip Arthroscopy for the Labral Injury and FAI - Shane J. Nho, MD, MS (CSMS #85, 2017) Knee & Sports - Femoroacetabular Impingement 11/17/2017 119 views Login to View Community Videos Login to View Community Videos 2017 Chicago Sports Medicine Symposium: World Series of Surgery Alterations in Hip Function in Persons with Femoroacetabular Impingement Syndrome - Phillip Malloy, MSPT, CSC (CSMS #82, 2017) Knee & Sports - Femoroacetabular Impingement 11/17/2017 33 views Upgrade to View Premium Videos Upgrade to View Premium Videos Adult Reconstruction Core Webinars - by AAHKS, Hip Society, Knee Society, and AAOS Core Webinar - HIP CONDITIONS & PRESERVATION - by AAHKS Knee & Sports - Femoroacetabular Impingement 2/10/2017 1156 views Login to View Community Videos Login to View Community Videos 2016 Chicago Sports Medicine Symposium FAI, Labrum Case Presentations, Question and Answer - Michael Salata, MD (CSMS #83, 2016) Michael Salata Knee & Sports - Femoroacetabular Impingement 10/26/2016 423 views Login to View Community Videos Login to View Community Videos 2016 Chicago Sports Medicine Symposium Chondral Defects: When to Debride or Microfracture? How Much OA Can You Accept? - Thomas Wuerz, MD (CSMS #80, 2016) Thomas Wuerz Knee & Sports - Femoroacetabular Impingement 10/26/2016 345 views Login to View Community Videos Login to View Community Videos 2016 Chicago Sports Medicine Symposium Approach to the Failed Hip Procedure - Michael J. Salata, MD (CSMC #79, 2016) Michael Salata Knee & Sports - Femoroacetabular Impingement 10/26/2016 211 views Login to View Community Videos Login to View Community Videos 2016 Chicago Sports Medicine Symposium Hip Instability: Traumatic, FAI-Induced, Microinstability, and Iatrogenic - Shane J. 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