Update on femoroacetabular impingement (FAI) · What are Risk Factors for Revision after Hip...

Dr. S. GhijselingsDienst Orthopedie, UZ Leuven

13/2/2018

Update on femoroacetabular impingement (FAI)

Casus

• Man - 31j

• Heuppijn bij voetballen

• Geen pijn bij wandelen

• Geen pijn ‘s nachts

Anamnese

• In auto zitten pijnlijk

• Pijn in lies regio

• Adductor letsels in voorgeschiedenis

• Pijn bij hoesten / niezen?

• Pijn buikspieren?

Heup impingement

Femoroacetabulair impingement (FAI)

What is FAI ?

FAI morphology FAI syndrome

What is FAI ?

FAI morphology

Definitions

Etiology

What is FAI ?

FAI morphology FAI syndrome

Symptoms

OA

Treatment

Ganz, CORR

CAM definition

Nötzli, JBJS Br 2002

Alpha angle

Axial MRI

Normal: 42°

Pathological: > 55°

Radial MRI

How prevalent is a CAM morphology?

• Depends on definition (XR – CT – MRI & alpha-angle)

• More in athletes (Football, Icehockey, Basketball, American Football,…)

• More in males

• Ethnic differences

5% 75%

AthletesGeneral population

10 - 20%

Etiology ??

Etiology of CAM

Dose response:

football 4 times /week on high level ?

Tak et al. BJSM 2015

After 12 y Before 12 y

CAM > 60° FLL 40% 64%

CAM > 78° FLL 12% 30%

When do CAMs develop?

Agricola, AJSM, 2014

• 63 preprofessional football players

• 14y (12 – 19y)

• AP & frog leg X-rays

• Base line – 2y follow-up

Concave Flat

Flat Bump

Open physis

Concave = concave

Flat = flat

Bump = bump

Closed physis

Agricola, AJSM, 2014

Cam deformities develop around age of 13 y

Increase in size during adolescence

Do not occur after physeal closure

Bone adaptation in response to athletic activities during growth

Pincer definition

Much less clear

Pincer definition

Much less clear

CEA > 39°Centre edge angle

Pincer definition

• Focal retroversion

• Global retroversion

• Profunda

• Protrusio

Pincer definition

• Focal retroversion

• Global retroversion

• Profunda

• Protrusio

Profunda Protrusio

How prevalent is a PINCER morphology ?

4% 71%

General population

• More common in women

• Influence of sports?

10%

Etiology ?

What is FAI ?

FAI morphology FAI syndrome

Symptoms

OA

Treatment

FAI syndrome

Symptoms + clinical signs + diagnosticimaging

Symptomatic premature contact between proximal femur andacetabulum

Griffin, Br J Sports Med, 2016

The Warwick Agreement (2016)

Motion – related clinical disorder

CAM impingement

- Shear force

- Delamination at chondrolabral

junction

Pincer impingement

- Linear contact

- Labral crush

- Contre-coup lesion

Symptoms

C – signTypical sign of intra-articular pathology

FADIR + limited internal rotation

X-rays

Technische onderzoeken

(arthro) - MRI heup Bekken

Does a CAM cause symptoms?

CAM > 50,5° RR 4,3 pain at 4,4yMRI, 1.30h

Only 15,9% hips with CAM developed hip pain. MOST DIDN’T

Khanna, AJSM, 2014

Cause of OA ?

Impingementmorphology

FAI Articular damage OA

Variables • Activity• Genetic factors• BMI• Gender• Ageing• Muscle balance• ….

- Cam- Pincer- Combined- Extra-articular- Femoral version- Acetabular version

Is a CAM a cause of OA?

Agricola, Ann Rheum Dis, 2013

CAM > 60° OR 3,6 end stage OA at 5y

> 83° OR 9,6

> 83° & IR <20° PPV 52% end stage OA

AP pelvic XR

CAM & OA

Not all CAMs become symptomatic !

CAM is a risk factor for hip pain & OA

The bigger the CAM, the more symptoms & OA

Pincer & OA

Conflicting evidence !

PINCER morphology FAI Articular damage /OA

Hosnijeh (Arthritis & Rheumatology, 2017)No increase risk of OA (CEA >40°) at 9,2y

Risk factor No effect Protective

Agricola (Osteoarthritis & Cartilage, 2013)CEA>40° AP + FP = OR 0,34 voor OA

Nicholls (Arthritis Rheum, 2011)No association pincer & THR at 19y

Gosvig (JBJS am, 2011) deep socket RR 2,4

Can we fix it ?

Impingementmorphology

FAI Articular damage OA

Variables • Activity• Genetic factors• BMI• Gender• Ageing• Muscle balance• ….

Conservative treatment

• Physiotherapy• Core stability training• Gluteus medius training• Stretching hamstrings + adductor• Pelvic tilt correction

• Intra-articular infiltration

• Avoid /stop painful activities

Surgery

Open chirurgische luxatie Heuparthroscopie

Geen degeneratieve veranderingenCave: vrouwen ouder dan 40 !

Indicatie voor heelkunde

Behandeling

Chirurgische heupluxatie

Arthroscopisch

Behandeling - open ingreep

Heuparthroscopie

Anterolateral portal

Trochanter

Anterior portal Mid - Anterior portal

Supine on traction table

SIAS

Heuparthroscopie

Anterolateral portal

Heuparthroscopie

FH

Acetabulum

Anterior portal

Heuparthroscopie

Capsulotomy• Interportal

• Limited

Anterior portal

Anterolateral portal

Heuparthroscopie

CAM resectie

Perifeer compartiment

Heuparthroscopie

Labrum herstel

Centraal compartiment

Heuparthroscopie

Microfracture

Centraal compartiment

Results

• 80% clinical improvement

• Low complication rate

• Long rehab: 3-6 months

• Risk factors

• Preop cartilage quality

• Under or over correction

• Age

• Labral repair > labral resection

97 hips (FU 10-13 years)

• 11 THA• 8 progressive OA• 3 poor clinical outcome

Risk factors: age >40 y, BMI, CEA < 22° or > 32°

Open dislocation

80% of patients with surgical dislocation have good clinical resultwithout OA progression at 10 years

Steppacher, CORR, 2015

20% failure

Arthroscopy

Haefeli, CORR, 2017

What are Risk Factors for Revision after Hip Arthroscopy for FAI at 7-years ?

52 hips (FU 5-11y, mean 7)

• 2 THA• 6 progressive OA• 6 poor clinical outcome

Risk factors: Pincer impingement, lateral CAM,residual FAI

15% failure

Osteoarthritis and Cartilage,2016

What evidence do we have?

6 RCT running+ Sham surgery

Take home message

FAI = dynamisch conflict

CAM = risico op heuppijn en artrose

Niet alle CAM’s symptomatisch

Initiële behandeling = conservatief

Heelkunde geeft goed resultaat naar pijn

Effect van heelkunde op artrose?

Kniepijn bij 10 – 16 jarige

11-jarig meisje met vage last in de lies of/ en de knie al enkele weken

25/1/2018

Kniepijn bij 10 – 16 jarige

11-jarig meisje met vage last in de lies of/ en de knie al enkele weken

25/1/2018

Kniepijn bij 10 – 16 jarige

11-jarig meisje met vage last in de lies of/ en de knie al enkele weken

R/ steunzolen

Kniepijn bij 10 – 16 jarige

• Acute toename van de pijn

• Onmogelijkheid tot steuname

• Gefixeerde exorotatie

• Verkorting

4/2/2018

Kniepijn bij 10 – 16 jarige

Epifysiolyse

Kniepijn bij 10 – 16 jarige

Kniepijn bij 10 – 16 jarige

Kniepijn bij 10 – 16 jarige

Epiphysiolyse

• Klachten dikwijls vaag en vaak aan banaal trauma geweten

• Gerefereerde pijn naar de knie

• De typische patient:

• obese jongen tussen 10 en 16

• maar!!…ook magere meisjes

• RX niet altijd overduidelijk

• Goed klinisch onderzoek: heuprotatie!

Bedankt

Stijn.Ghijselings@uzleuven.be

UZ Pellenberg

Afspraken via Orthopedie@uzleuven.be