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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!
