F e m o roa c e t a b u l a r I mpingement

Current Concepts and Controversies
Wudbhav N. Sankar, MDa,*, Travis H. Matheney, MDb, Ira Zaltz, MDc
KEYWORDS 
Femoroacetabular impingement  CAM lesions  Pincer lesions  Osteoarthritis  Impingement

KEY POINTS 
Femoroacetabular impingement (FAI) is a clinical syndrome of hip pain, limitation in movement, and joint damage from abnormal mechanical contact of the acetabular rim and the proximal femur.  There is a high prevalence of morphologic abnormalities associated with FAI in asymptomatic individuals.  Cross-sectional and longitudinal studies support FAI playing a causative role in the development of osteoarthritis and need for total hip arthroplasty in certain patients.  Surgical treatment approaches for FAI include hip arthroscopy, anterior mini-arthrotomy with/ without arthroscopic assistance, and surgical dislocation of the hip.

WHAT IS FEMOROACETABULAR IMPINGEMENT?
The modern concept of femoroacetabular impingement (FAI), especially its causal relation to acetabular labral and cartilage damage, emerged following the observation that FAI can be precipitated by acetabular reorientation and can produce new labral damage.1 Following this observation, interest in the association between chondrolabral damage and variations in femoral and acetabular anatomy has established a causal relationship between mechanical aberration in the function of the hip joint and the development of labral and cartilage damage.2,3 The resulting modern accepted definition of FAI is that it is characterized by abnormal mechanical contact between the rim of the acetabulum and the upper femur. Certain anatomic femoral or acetabular morphologies,

hip-specific supraphysiologic flexion or rotational movements, repetition, and forceful motions may damage the acetabular labrum and the cartilage around the rim of the acetabulum, leading to a clinical syndrome of hip pain, limitation of movement, and joint damage now known as FAI.

CLASSIFICATION
Two distinct hip morphotypes have been described that are associated with intracapsular, mechanical FAI. The CAM morphotype of FAI is an aspherical epiphyseal extension that produces a characteristic bump at the junction of the femoral head and femoral neck (Fig. 1). The origin is thought to be caused by an extension of the upper femoral epiphysis along the anterolateral femoral neck junction4; however, the pathogenesis of this bump is not well understood and may represent

a Division of Orthopaedic Surgery, The Children’s Hospital of Philadelphia, 2nd Floor Wood Building, 34th and Civic Center Boulevard, Philadelphia, PA 19104, USA; b Department of Orthopaedic Surgery, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; c Department of Orthopaedic Surgery, William Beaumont Hospital, 3535 West 13 Mile Road, Royal Oaks, MI 48073, USA * Corresponding author. E-mail address: sankarw@email.chop.edu

Orthop Clin N Am 44 (2013) 575–589 http://dx.doi.org/10.1016/j.ocl.2013.07.003 0030-5898/13/$ – see front matter Ó 2013 Elsevier Inc. All rights reserved.

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radial magnetic resonance imaging (MRI) reconstructions are often used to more accurately assess the morphology of the head-neck junction and minimize the chance of missing CAM lesions (Fig. A crossover sign accompanied by a posterior wall sign may be associated with anterior impingement when the hip is flexed and posterosuperior instability when the hip is in extension. 2). Although the crossover sign may represent true focal acetabular overcoverage in some cases. resulting in so-called mixed-type impingement. The larger the alpha angle. The alpha angle is the angle formed between a line drawn down the axis of the femoral neck and a line drawn to the point at which the contour of the femoral head-neck junction deviates from the perfect circle. There is general agreement that a normal LCE is between 25 and 35 and that hips with an LCE greater than 40 are at risk for impingement in flexion. There is conflicting information regarding the sensitivity of the crossover sign. The coverage of the acetabulum relative to the femoral head is traditionally assessed using the lateral center-edge angle (LCE). These features are recognizable radiographically using an anteroposterior (AP) pelvis radiograph. Focal overcoverage can be assessed using the crossover sign that is observed when the anterior acetabular wall crosses over the posterior acetabular wall on a properly oriented AP pelvis radiograph (Fig. focal overcoverage. As the hip comes into flexion and internal rotation. location.6 A best-fit circle is first the alpha angle of No drawn around the femoral head. larger alpha angle measurements indicate a more aspherical femoral head. and retroversion of the acetabulum. The degree of asphericity can be quantified using ¨ tzli. which occurs when the posterior wall of the acetabulum is located medial to the center of the femoral head. and results in premature contact between the femoral neck and acetabular rim when the hip is flexed (Fig. 1.6 The alpha terized by the alpha angle of No angle estimates the degree at which the radius of curvature of the femoral head begins to increase. Lateral view of the hip shows the typical appearance and location of a CAM lesion. Image from a radial sequence MRI showing reduced offset at the femoral head-neck junction. however. the greater the degree of asphericity. PATHOPHYSIOLOGY The mechanics of impingement limit the degree of sagittal plane hip motion. the severity of deformity can be charac¨ tzli. causing impingement.576 Sankar et al Fig. the ability to visualize the prominence using plain radiographs is variable. when a crossover sign is accompanied by a posterior wall sign. 3). this prominence can abut the acetabular rim and labrum. crosstable lateral.7–9 In addition.10 Many hips are thought to have features of both CAM-type femoral morphology and acetabular overcoverage. Because of this variability. a distinct type of upper femoral chondroepiphyseal maturation. in others it may be artifactually caused by the orientation of the anterior inferior iliac spine.5 Because the size. Thus. the acetabulum may be retroverted and the posterosuperior femoral coverage may be insufficient. 4). and extension of the deformity are unique for each hip. Fig. 2. or Dunn-lateral views may be used. On either plain radiographs or radial sequences. Frog-lateral. diminishing the degree . the reliability depends on the location of the deformity and the rotation of the limb during the radiograph. Acetabular-sided deformity or pincer impingement includes global overcoverage.

11 Normal mechanical gait parameters are altered in patients affected by CAM-type FAI.Femoroacetabular Impingement 577 Fig. The presence of both signs on a properly oriented AP pelvic radiograph suggests acetabular retroversion. 4. the femoral head-neck junction prematurely abuts the edge of the deep acetabulum. Impingement was modeled by increasing the alpha angle and the acetabular depth using a Fig. 3. with demonstrated decrease in hip abduction and frontal plane motion compared with control hips. Pincer morphology from an excessively deep hip socket. This impingement can also cause levering of the femoral head away from the joint. The posterior wall sign is formed when the edge of the posterior wall lies medial to the center of the femoral head. to which an affected individual is able to squat. causing primary injury to the labrum and peripheral articular cartilage. resulting in posterior shear and contrecoup chondrolabral lesions. Radiographic signs suggesting acetabular retroversion. .12 Chegini and colleagues13 used computational models to analyze stresses along the acetabular rim in simulated dysplastic and impinging joints. which can be a cause of pincer impingement. The crossover sign is formed when the anterior acetabular wall crosses over the posterior acetabular wall. With motion.

080 asymptomatic military recruits in Sumiswald. and/or alpha angle >50 ). The impingement test.2 CAM-type impingement. hip guarding and compensatory lumbar Fig. causes labral distortion and shear forces within the peripheral acetabulum that can cause detachment of the labrum from the rim of the acetabulum and full-thickness or partial-thickness delamination injuries of the hyaline cartilage within the joint. such as crouching or sitting.19 Because the symptoms caused by FAI are not disease specific. a calculated conclusion that is consistent with damage observed clinically in impinging joints at the time of surgery. have been observed clinically. lower back. The classic provocative maneuver is the anterior impingement test. Switzerland. In addition. thought to be related to remodeling caused by chronic and repetitive contact between the acetabular rim and femoral neck. 5. Based on radiographic signs of FAI (herniation pits. thought to result from anterior levering of the femur causing posterior shear. or the anterior thigh and knee. and internal rotation of the affected hip. The reported prevalence of FAI varies widely depending on the parameters used to define the condition. the damage pattern in hips with pincer-type mechanics is more peripheral. and internal rotation of the affected hip (Fig. center-edge angle >39 . The pain pattern often goes unrecognized by primary physicians. contrecoup chondrolabral lesions in the posterior acetabulum. several recent studies have established a high prevalence of morphologic abnormalities associated with FAI in asymptomatic individuals as well:  Reichenbach and colleagues21 reported on 1. The labrum is therefore crushed between the bony acetabular rim and femoral neck and the peripheral-most acetabular cartilage may become detached and frayed. leading to missed diagnosis or misdirected treatment. which is pain elicited by flexion. trochanteric region.2 The two major differences between CAM-type and pincer-type injury patterns are the increased depth of chondral injury associated with the CAM mechanism. The test is considered positive if pain is elicited by flexion. Ochoa and colleagues20 reviewed 155 patients with a mean age of 32 years (range. pistol grip deformity. crossover sign. Other provocative tests include the resisted straight-leg raise and the posterior impingement test. Range of motion is usually limited in hips that are morphologically prone to symptomatic FAI. The physical examination of a patient with symptomatic FAI is characterized by painful limitation of hip flexion. and 81% had at least 2 findings.13 These mechanical studies support theories developed by observing patterns of chondral injury at the time of surgical treatment. 18–50 years) who presented to primary care or orthopedic clinics with a chief complaint of hip pain. and confinement of damage to the rim and peripheral acetabulum in pincer-type impingement. with average flexion reportedly slightly greater than 90 . Clinical symptoms and physical examination signs must be correlated with radiographic data to firmly establish the diagnosis of FAI. Pain may be precipitated by athletic activity or activities that require flexion. adduction.2. In patients with highly irritable hip joints. 5). However. These hips often have a characteristic trough located in the femoral neck. careful patient history is essential when entertaining the diagnosis of FAI. of whom 430 were CLINICAL PRESENTATION The presentation of patients with symptomatic anterior FAI has been described by multiple investigators.17–19 Patients usually present with insidious-onset pain about the hip that is characteristically localized to the groin but may be experienced in the buttock. motion may confound the physical examination.14–16 In contrast. adduction. the investigators reported that 87% of the patients had at least 1 finding consistent with FAI. .3. in which an aspherical bump enters the acetabular fossa during flexion.578 Sankar et al standing-to-sitting motion and was shown to cause distortion and shearing at the bone-tissue interface. PREVALENCE OF DISEASE The prevalence of clinically significant FAI remains unknown.

 CAM morphology was defined as a ratio of head to neck diameter less than 1. mean age was 66 years. Recent epidemiologic studies have attempted to clarify the role of FAI in the pathogenesis of osteoarthritis:  The Nottingham United Kingdom Genetics of Osteoarthritis and Lifestyle (GOAL) study examined the morphology of the hip in 566 persons with unilateral hip osteoarthritis and compared this to the contralateral asymptomatic hip to non-osteoarthritic control hips from 1.9 years  Adjusted overall prevalence of CAM-type deformity was 24% [95% CI 19. or the reaction to the arthritic process (osteophytes).21  Jung and colleagues22 evaluated 838 asymptomatic hips in 419 randomly selected patients aged 25 to 92 years who underwent abdominal or pelvic computed tomography (CT) for medical diseases unrelated to the hip. The presence of imaging findings consistent with FAI alone is not sufficient to warrant intervention.4 to 50. physical examination.27. .28  All patients were 45 years of age or older. to undergo a radial sequence MRI looking for abnormal morphology at the femoral headneck junction.25 and holds that the morphologic abnormalities of the femoral head and/or acetabulum result in abnormal contact between the femoral neck/ head and the acetabular margin.  For women. 579 CAUSATIVE ROLE IN OSTEOARTHRITIS The contemporary theory of FAI as a causative factor in the development of osteoarthritis has been championed by Ganz and colleagues.  Ages ranged 25 to 92 years  Men <50 years of age: mean a-angle was 57. and 244 agreed. Normal (68 ). Articular cartilage injury secondary to CAMtype FAI. Pathological (57 ) 2. This abnormal contact leads to supraphysiologic stress causing tearing of the labrum and avulsion of the underlying cartilage region (Fig.  Women <50 years of age: mean a-angle was 45.6 years.  At the 1:30 position.  Ages ranged 21. Fig.100 subjects who had undergone intravenous urograms. questions remain as to whether FAI is a cause or a result of osteoarthritis and whether joint deformities in FAI are congenital. with eventual onset of arthritis. Borderline (51 to 56 ) 3. The treating clinician must rely on the history. Normal (50 ). These prevalence data in patients with minimal or no symptoms show the importance of clinical correlation during the diagnostic work-up for FAI.4 years  a-angles were measured at both the 3 o’clock and 1:30 position with CAM deformity defined as an angle exceeding 50. and imaging findings to determine whether a symptomatic patient is symptomatic because of FAI.27 The continued abnormal contact results in further deterioration and wear of the articular cartilage.3 with 7% demonstrating pathologic a-angles  Hack and colleagues24 studied 200 asymptomatic volunteers using radial MRI reformats. Borderline (69 to 82 ) 3. 30]. 6).  For men. However. 53% of the volunteers had evidence of CAM morphology  At the 3 o’clock position. the three categories for a-angle ranges were: 1. AP scout views of CT scans were used to measure asphericity of the femoral headneck junction using the alpha angle as ¨ tzli and colleagues. developmental. the three categories for a-angle ranges were: 1.2 with 14% demonstrating pathologic a-angles.5 .  Mean age was 19. 14% had elevated a-angles. mean 29. Pathological (83 ) 2.  48% of the subjects were women.26.6 Study described by No participants were classified according to criteria defined by Gosvig and colleagues23 based on the Copenhagen Osteoarthritis Study. 6.Femoroacetabular Impingement randomly selected.

 The Chingford cohort provides another recent longitudinal study of the relationship between hip morphology and the development of osteoarthritis.6% risk in the control group. In addition.  A pistol grip deformity conferred an 8. Of those patients who went on to THA. the baseline hip morphology was compared to a random sample of 243 hips that did not require THA. are common in young adult hips and predisposes to the later development of osteoarthritis in certain patients.  Both factors were strongly and significantly associated with an increased risk of developing hip osteoarthritis after adjusting for age. Recent evidence also suggests that FAI morphology may result from early exposure to high-impact sports. in most hips the presence of a CAM lesion is not sufficient in isolation to lead to the development of clinically significant and symptomatic osteoarthritis. and gender.  Hips with a baseline AP a-angle >83 had a 25% risk of developing end-stage osteoarthritis within 5 years compared to a less than 2% risk of end-stage osteoarthritis in hips with an a-angle less than 83 (odds ratio of 9. and may therefore be developmental in origin rather than a reaction to the arthritic process. the investigators reported a 5. these radiographs were repeated.05 for each 1 increase in initial a-angle. which was measured the presence of CAM and pincer deformity. and subjects were followed for 5 years to determine the risk of developing end-stage osteoarthritis. BMI and baseline Kellgren-Lawrence grade).3% risk of developing osteoarthritis in the contralateral non-osteoarthritic hip compared to a 3. which exceeds the reported prevalence in asymptomatic members of the general population. At 19 year follow-up.5% risk of developing osteoarthritis in the contralateral non-osteoarthritic hip compared to a 3% risk in the control group. TREATMENT Treatment of FAI has evolved greatly over the past decade. there is insufficient evidence from longitudinal population studies to confirm a similar association between the presence of a pincer deformity and the development of clinical or radiographic osteoarthritis. by measuring proximal femoral morphology before it is altered by osteoarthritis:  A prospective study of FAI in the Cohort Hip and Cohort Knee (CHECK) study reported on a Dutch national sample of 723 patients presenting for the first time with recent onset of hip or knee pain. Based on the previously mentioned studies in which FAI morphology was studied before the presence of radiographic osteoarthritis and the prevalence studies in young.580 Sankar et al  Based on this criterion. the presence of CAM deformities at baseline substantially increases the risk of developing osteoarthritis and the need for a THA. in both men and women aged 45 to 65 years. body mass index. Kapron and colleagues31 reported that 95% of 134 hips in collegiate football players had at least one radiographic sign of CAM or pincer impingement. in large part because of an increased recognition of the different morphologic factors that contribute to FAI as well as the development of new surgical techniques for reshaping the proximal femur and acetabular rim. However.27 . In addition to this representative cross-sectional study. and its morphologic risk factors. longitudinal studies of FAI have established the temporal relationship of cause to effect.  The odds ratio of needing a THA increased 1.7 adjusted for age.29 Initial AP pelvic radiographs were measured to determine the a-angle. and suggested that repeated high-stress activities during childhood may modulate growth of the proximal femur toward an abnormal shape via subclinical physeal injury. asymptomatic persons it is clear that FAI.  Ages ranged 45 to 65 years  80% of the cohort was female  Subjects had no osteoarthritis at baseline with either a Kellgren-Lawrence osteoarthritic grade of 0 (76%) or grade 1 (24%).  Hips with both an a-angle >83 and decreased internal rotation 20 had a 53% risk of developing end-stage osteoarthritis within 5 years.4 at baseline compared to 45. Siebenrock and colleagues32 showed a 10-fold increase in the prevalence of CAM morphology in a cohort of elite basketball players compared with nonactive agematched controls.  Ages ranged 44 to 67 years  Median AP a-angle in those who required THA was 62.30 1003 healthy female subjects were enrolled after undergoing a baseline AP radiograph of the pelvis. sex.8 in controls (P 5 . At this point. the investigators showed increasing alpha angles in the athletes during skeletal maturation.001). Longitudinal studies also support that.

Surgical Dislocation  Technique: performed through a lateral Gibson approach to the hip with a digastric trochanteric osteotomy and anterior-based arthrotomy. Following this. it has Fig. For the purposes of discussing and comparing these techniques.Femoroacetabular Impingement The successful treatment of FAI demands:  Accurate diagnosis. and the inferior portion of anterior inferior iliac spine 581 NONOPERATIVE MANAGEMENT Because of the high prevalence of FAI morphology in asymptomatic hips. Medical and/or conservative management may also be of particular benefit when there is evidence of advanced arthrosis for which a joint-preserving procedure is not indicated. a thorough understanding of the three-dimensional anatomy of the hip and the surgical techniques available to address its pathomorphology are paramount to ensure that any procedure remains safe as well as being efficacious. anterior mini arthrotomy. soft tissue impingement/inflammation. labral repair. including the cotyloid notch. a nonarticular cause. In general. acetabular chondroplasty.24. As previously noted. the following terminology is used to describe the regions around the hip joint:  Central compartment: the area within the acetabulum. iliopsoas. Some surgeons favor postoperative SURGICAL MANAGEMENT Since the initial description of his surgical dislocation approach to the hip. articular surface of the acetabulum. Once all portions of the hip joint are exposed. The capsule is repaired and the trochanteric fragment reattached with screws. with or without arthroscopic assistance. 7). and ligamentum teres  Peripheral compartment: the area outside the acetabulum. with improved familiarity with the vascular anatomy of the proximal femur. acetabular lesions are addressed. labrum. Can patients change their lives to mitigate their symptoms?  Expectations  Knowledge of the surgeon’s surgical skill set: can clinicians gain adequate access to address all disorders through open approaches. depending on the patient and the clinical picture. or a combination of the two? become safe to gain access to the hip joint without concern for avascular necrosis. (A) Intraoperative appearance of a CAM lesion visualized through a surgical dislocation approach. 7. the first critical step is the accurate diagnosis of the cause of pain and arthrosis. or both?  A clear understanding of the possible pathomorphologies that can lead to arthrosis  A concomitant understanding of other possible causes of hip pain and arthrosis (eg. (B) Intraoperative view of femoral head-neck osteoplasty shows improved contour and restoration of offset. conservative management is usually warranted as an initial step. Is the pain caused by FAI. arthroscopy. This ability has laid the groundwork for the expansion in surgical treatment options for FAI. and activity/lifestyle modification can all be used. .31 Modalities including physical therapy to alleviate symptoms associated with periarticular causes. there are 3 surgical techniques currently used to treat FAI pathomorphology: surgical dislocation of the hip. including the acetabular rim. followed by femoral osteochondroplasty as needed (Fig. joint capsule. antiinflammatories. including rim resection. femoral neck. concomitant developmental dysplasia of the hip)  Assessment of patient-based factors  Age  Demands. Ganz and colleagues33 noted that. and arthroscopy.

midanterior. and anterior. or labral repair through the arthroscope. .  Cons: to properly address all possible lesions within the hip with FAI morphology demands an advanced arthroscopic skill set that allows the surgeon to correct acetabular rim lesions and perform labral repair and femoral osteochondroplasty. and femoral neck. who may be comfortable with arthroscopy for chondral debridement but not osteochondroplasty. patients can be mobilized with physical therapy more aggressively without concern for affecting osteotomy healing. With or Without Arthroscopic Assistance  Technique: when used.  Regions accessible within the hip: central (limited central with arthrotomy alone) and limited peripheral compartment. Traction is used while assessing the central compartment. and potential for trochanteric nonunion and painful screws. rim resection. especially beneficial for treating posterior acetabular rim and posterior hip joint lesions. it may be more susceptible to rotational forces and therefore hip-strengthening exercises may need to be limited until there is trochanteric union. There is also incomplete access and visualization of the posterior hip joint and acetabular rim.  Pros: less soft tissue dissection and no osteotomy but still able to visualize the central compartment to treat chondral injuries (with arthroscopy) as well as providing access to treat CAM lesions. Anterior Mini Arthrotomy.  Regions accessible within the hip: central and limited peripheral compartment (poor access to posterior regions of the hip joint and acetabular rim).582 Sankar et al abduction precautions.  Cons: treatment of acetabular rim lesions with rim resection and labral repair is difficult. Allows easy repair of the joint capsule. Arthroscopy  Technique: typically performed with the patient either supine or in a lateral position and a combination of portals including the peritrochanteric. labrum. This step is followed by an anterior arthrotomy performed through a standard anterior approach to perform the femoral osteochondroplasty and possibly labral debridement and limited acetabular rim resection.  Cons: more invasive surgery. Proponents of arthrotomy alone think that they can attain adequate access to the anterior acetabular rim. which may be of benefit in preventing later hip instability. there is increasing emphasis on the ability to perform a capsular repair. Beneficial for the surgeon Fig. 8). (A) Arthroscopic view of the peripheral compartment shows prominence and injury of the head-neck junction from CAM-type FAI. However. Without trochanteric osteotomy. In addition.  Pros: potentially the smallest amount of surgical dissection of superficial tissues and no trochanteric osteotomy. then released to perform femoral osteochondroplasty and assess range of motion/ adequacy of femoral neck resection (Fig.  Pros: complete visualization and access to both the acetabulum and femoral head. longer course of recovery. arthroscopy is typically performed first under traction to assess the central compartment and perform chondroplasty and labral debridement as needed. Such precautions are most likely not necessary because it is a digastric osteotomy and under compression in abduction. 8. (B) Arthroscopic view after femoral head-neck osteochondroplasty.  Regions accessible within the hip: central and complete peripheral compartment.

the accurate determination of outcomes is difficult. With regard to the deformity. ranging from 0% to 5%. These studies included older patients with more advanced arthrosis and concurrent dysplasia.46 An argument can be made that more recent literature reflects outcomes FUTURE DIRECTIONS FAI as a clinical entity is in its infancy and understanding of the condition will undoubtedly increase in the years to come. when this is combined with surgeon-related and surgeryrelated variables. more knowledge is needed about the importance of normal structures around the hip in the course of treating the more .46. transient lateral femoral cutaneous nerve injuries. following refinement of surgical indication and technique in which the THA conversion rate is only 0% to 5%.58.41. pincer.34. continued close follow-up is critical because the rate of progression to advanced arthrosis is unpredictable and may lead to an inability to keep hip-preserving surgery as a viable option.44 the complication rates ranged from 0% to 17% and included several inadequate resections requiring revision osteoplasty and/or labral fixation. A prominent point brought out in the current literature is that the learning curve for arthroscopic treatment is not well defined and may have an important effect on the individual surgeon’s outcomes. Areas in need of further study include the natural history of FAI morphology.48 583 Anterior Mini Arthrotomy.43. and 1 femoral neck fracture treated nonoperatively. both). work and sport demands. several studies have evaluated the use of arthroscopy to treat FAI morphology rather than just labral debridement. provided there are ongoing follow-up evaluations. short-term to mid-term results are good to excellent with few complications. patient expectations. with less frequent pudendal or lateral femoral cutaneous nerve palsy and (given the number of described cases in some series of more than 1000 arthroscopies) few reported revisions.27. Matsuda and colleagues44 performed a systematic review of reported outcomes and. With or Without Arthroscopic Assistance In groups that accessed the hip joint primarily via an anterior arthrotomy.39. Nonoperative Management Few outcome data exist for the nonoperative management of FAI. include mixed patient populations with variable types of impingement (CAM. primarily from trochanteric nonunion. across a wide spectrum of ages and causes (Fig.57–59 However. Patient-related factors such as lifestyle.34–55 Most studies reporting surgical outcome are single-surgeon experience. It has been used to treat a broad spectrum of deformity.35. many patients may opt for continued conservative therapy. stating that. in general.42. and other potentiating factors that explain why certain people with FAI become symptomatic and others do not.33 surgical dislocation has remained the gold standard treatment of FAI.40 In these cases and in the asymptomatic patient.38.60–64 Most of these studies were short-term follow-up (1–2 years on average) and showed a conversion rate to THA of 0% to 9%.Femoroacetabular Impingement OUTCOMES The outcome of the surgical treatment of FAI is variable.51. the most commonly previously performed arthroscopic hip procedure. particularly pincer deformities. the results may not be transferrable.36. The published success rate ranged from 67% to 90%. One investigator advocated an initial trial of conservative therapy and activity modification in symptomatic patients with prearthritic intra-articular hip disorder. The conversion to THA as an end point for failure has been reported to be 0% to 30%.50. Because the presentation can vary substantially. In the 4 reports cited by Matsuda and colleagues.49. use a variety of methods to describe the deformity. the incision lengths described for the mini open ranged from 2 to 12 cm. outcomes were similar to those obtained in the more recent surgical dislocation group (71%–92% success rate). and duration of symptoms can all play a role. 9). Because most of these series were single-surgeon reports. span a range of surgical experience. and have short-term (minimum 1 year) to midterm (average 5–6 year) follow-up (Table 1).38. Reported success rates across different studies ranged from 65% to 94%. Surgical Dislocation Since its initial description by Ganz and colleagues.56 Arthroscopy With the advent of improved technique.54.44. use a variety of outcome instruments. with or without arthroscopic assistance.2.53. Complication rates were the lowest of the 3 surgical groups. whereas complication rates ranged from 0% to 20%.55 Studies reporting higher rates of conversion to THA were earlier reports and in these initial patient cohorts the best indications for surgery had not been elucidated.

1 pts [ 12.1 4.43 2009 Mixed Mixed mHHS mHHS [ 24 pts [ 17 pts 6% converted to THA 0% CAM CAM NAHS mHHS [ 29.55 2009 Anterior arthrotomy Æ Arthroscopy Laude 100 4.584 Sankar et al Table 1 Selected outcome studies for FAI Study No. 94% with labral refixation NR 30% converted to THA Peters 96 2.2 Mixed Conversion to THA [ 20.46 2004 23 5.49 2010 Yun 15 >1 et al.3 pts 11% converted to THA 6% NR NR .18 2006 60 3.7 2 CAM CAM Pincer Æ CAM Murphy et al.36 2004 19 Espinosa et al.2 et al.2 pts [ 2. UCLA. others WOMAC.7 pts 68% good to excellent 76% good to excellent with labral debridement.9 et al. Hips Mean FU (y) 1 Type of FAI Mixed Outcome Measure Satisfaction.35 2007 Beck et al. need for surgery. SF-12 ´ Merle d’Aubigne ´. Merle d’Aubigne ¨ nnis grade of To arthrosis Outcomes 44% satisfied “Failures” 56% eventually chose surgery 16% dissatisfied 26% 4% with labral debridement Predictors of Failure Desire for “more active lifestyle” Advanced arthrosis ¨ nnis 1) Advanced (>To arthrosis Results significantly better after rim trim with refixation of labrum vs debridement alone Advanced arthrosis or combined impingement and instability Advanced arthrosis NR Non-Operative Treatment 58 Hunt et al.40 2012 Surgical Dislocation ´ Beaule 37 et al.58 2009 16 2 Lincoln et al.

41 2008 Philippon et al.3 Mixed Satisfaction mHHS 84% reported improved symptoms Median 9/10 [ 26 pts 16% deteriorated 9% converted to THA Byrd & Jones.5% converted to THA Grp 1: 9.Nepple et al.59 2009 Arthroscopy (grp 1) vs arthroscopy with osteoplasty (Grp 2) Ribas et al. WOMAC.63 2012 FAI correction plus (Grp 1: labral debridement) or (Grp 2: labral repair/ refixation) 207 Grp 1: 44 Grp 2: 50 1. modified Harris Hip Score.3 1.60 2009 Larson et al.53 2007 Arthroscopy Ilizaliturri et al.3 3. .1 pts 3% Advanced ¨ nnis 2) (To arthrosis NR 19 2. decreased pre-op Harris Hip Score.1% Grp 2: 8. NAHS. UCLA. University of California Los Angeles activity score.4 CAM Clinical 112 2. Western Ontario and McMaster Universities Arthritis Index. THA.0% Increased age. not reported. trend toward higher HHS in Group 2 Grp 1: 26% Grp 2: 4% NR 35 2. total hip arthroplasty.50 2009 Grp 1: 36 Grp 2: 39 2. NR.4 CAM ´ Merle d’Aubigne [ 3. minimum joint space <2 mm NR NR Femoroacetabular Impingement 585 Abbreviations: mHHS. Non arthritic hip score.5 Mixed Pincer Æ CAM mHHS mHHS SF 12 VAS Pain [ 24 pts 68% good to excellent results in Grp 1 vs 92% in Grp 2 0.7 CAM mHHS 74%–92% Good to Excellent.

. (A) AP and (B) lateral view of the right hip showing a typical CAM lesion at the femoral head-neck junction. In terms of treatment. an intact labrum. Eijer H. et al. Note the improvement in the head-neck contour and the screws used to repair the trochanteric osteotomy. Hip morphology influences the pattern of damage to the acetabular cartilage: femoroacetabular impingement as a cause of early osteoarthritis of the hip. Leunig M. In addition.363:93–9. the development of a comprehensive grading system for FAI would lay the foundation for comparative studies. Ganz R. J Bone Joint Surg Br 2005. 2. Kalhor M. longer follow-up studies with standardized outcome measures are necessary to determine the optimal treatment of particular patterns of disease. Anterior femoroacetabular impingement after periacetabular osteotomy. obvious disorders (eg. (C. Myers SR.87(7):1012–8. 9.586 Sankar et al Fig. capsular repair). importance of the ligamentum teres. D) AP and lateral view after osteochondroplasty was performed via an open surgical dislocation approach. Clin Orthop Relat Res 1999. Beck M. REFERENCES 1.

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