Femoral Acetabular Impingement Important

Tannast et al.
M u s c ul o s kel et a l I m ag i n g • R ev i ew
Femoroacetabular
Impingement
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Femoroacetabular Impingement:
Radiographic Diagnosis—What the
Radiologist Should Know
Moritz Tannast1 OBJECTIVE. The purpose of this article is to show the important radiographic criteria that
Klaus A. Siebenrock1 indicate the two types of femoroacetabular impingement: pincer and cam impingement. In addi-
Suzanne E. Anderson2,3 tion, potential pitfalls in pelvic imaging concerning femoroacetabular impingement are shown.
CONCLUSION. Femoroacetabular impingement is a major cause for early “primary” os-
Tannast M, Siebenrock KA, Anderson SE teoarthritis of the hip. It can easily be recognized on conventional radiographs of the pelvis and
the proximal femur.
emoroacetabular impingement (pre- lar impingement do not have classic radio-
F viously also called “acetabular rim

syndrome” [1] or “cervicoacetabu-
lar impingement” [2]) is a major
graphic signs of osteoarthritis such as joint
space narrowing, osteophyte formation,
subchondral sclerosis, or cyst formation.
cause of early osteoarthritis of the hip, espe- Thus, this article will familiarize radiolo-
cially in young and active patients [3–6]. It is gists with this pathophysiologic concept and
characterized by an early pathologic contact describe the radiographic findings that are
during hip joint motion between skeletal prom- helpful for the correct diagnosis and evalu-
inences of the acetabulum and the femur that ation before potential surgical treatment of
limits the physiologic hip range of motion, typ- femoroacetabular impingement. In addition,
ically flexion and internal rotation. Depending potential pitfalls simulating femoroacetabu-
on clinical and radiographic findings, two lar impingement are discussed, and some
types of impingement are distinguished “pearls” for diagnosis are offered.
(Fig. 1): Pincer impingement is the acetabular
cause of femoroacetabular impingement and is Clinical Findings
Keywords: bone, femoroacetabular impingement, hip,
characterized by focal or general overcoverage Patients with femoroacetabular impinge-
musculoskeletal imaging, orthopedic surgery, radiography of the femoral head. Cam impingement is the ment are young, usually in their 20s–40s.
femoral cause of femoroacetabular impinge- The estimated prevalence is 10–15% [11].
DOI:10.2214/AJR.06.0921 ment and is due to an aspherical portion of the Patients present with groin pain with hip ro-
femoral head–neck junction (Fig. 2). Most pa- tation, in the sitting position, or during or af-
Received July 25, 2006; accepted after revision
November 8, 2006. tients (86%) have a combination of both forms ter sports activities. Some patients describe
of impingement, which is called “mixed pincer a trochanteric pain radiating in the lateral
1Department of Orthopaedic Surgery, Inselspital, and cam impingement,” with only a minority thigh. Typically, they are aware of their lim-
University of Bern, Switzerland. (14%) having the pure femoroacetabular im- ited hip mobility long before symptoms ap-
2Department
pingement forms of either cam or pincer pear. In the clinical examination, patients
of Diagnostic, Pediatric and Interventional
Radiology, Inselspital, University of Bern, Switzerland. impingement [7]. with femoroacetabular impingement have a
During sports activities and activities of restricted range of motion, particularly flex-
3Present address: Royal Melbourne Hospital, University of
daily living, repetitive microtrauma of these ion and internal rotation [3, 8]. A positive
Melbourne, Melbourne, Australia. Address correspondence osseous convexities occur. As a consequence impingement sign is present for anterior
to S. E. Anderson (andersonsembach@yahoo.com.au).
of this recurring irritation, the labrum degen- femoroacetabular impingement if the forced
CME erates [8] and irreversible chondral damage internal rotation/adduction in 90º of flexion
This article is available for CME credit. See www.arrs.org occurs that progresses and results in degener- is reproducibly painful, and for posterior
for more information. ative disease of the hip joint if the underlying impingement with painful forced external
AJR 2007; 188:1540–1552
cause of femoroacetabular impingement is rotation in full extension [3, 12] (Fig. 3).
not addressed [9, 10]. The “Drehmann’s” sign is positive if there is
0361–803X/07/1886–1540
In the initial phase of this recently dean unavoidable passive external rotation of
© American Roentgen Ray Society scribed entity, patients with femoroacetabu- the hip while performing a hip flexion [13].
1540 AJR:188, June 2007

Femoroacetabular Impingement
Fig. 1—Flowchart shows Femoroacetabular Impingement

Conventional Radiographic
classification of types of Imaging Technique
femoroacetabular
impingement. The role of imaging in femoroacetabular
Acetabulum Femur
(excessive coverage) (nonspherical head) impingement is to evaluate the hip for abnor-
= Pincer impingement = Cam impingement
malities associated with impingement and to
exclude arthritis, avascular necrosis, or other
General Focal Osseous bump Femoral joint problems on radiographs. MRI or MR ar-
retrotorsion,
Coxa vara thrography can then be used to confirm or ex-
Coxa Protrusio Anterior Posterior Lateral Anterosuperior clude labral tears, cartilage damage, and other
profunda acetabuli (acetabular (prominent (pistol-grip
retroversion) posterior wall) deformity)
pathologic signs of internal hip derangement if
impingement is suspected. Alternatively, radi-
Fig. 2—Normal ography is then usually followed by MRI for
configuration of hip with cartilage and labral disorders and a 3D under-
sufficient joint clearance standing of the bone anatomy.
allows unrestricted
range of motion (top). In
Standard conventional radiographic imag-
pincer impingement, ing for femoroacetabular impingement in-
excessive acetabular cludes two radiographs (Fig. 4): an antero-
overcoverage leads to posterior pelvic view and an axial cross-table
early linear contact
between femoral view of the proximal femur [3]. An alternative
head–neck junction and to the axial view, a Dunn/Rippstein view,
acetabular rim, resulting preferably in 45º of flexion, can be obtained
in labrum degeneration
and significant cartilage to reveal pathomorphologies of the anterior
damage. Posteroinferior femoral head–neck junction [14]. For the an-
portion of joint is teroposterior pelvic radiograph, the patient is
damaged (contrecoup)
in the supine position with the legs 15º inter-
due to subtle
subluxations (center). In nally rotated to compensate for femoral an-
cam impingement, tetorsion and to provide better visualization
aspherical portion of of the contour of the lateral femoral
femoral head–neck
junction is jammed into head–neck junction [15]. The film-focus dis-
acetabulum (bottom). tance is 1.2 m; the central beam is directed to
the midpoint between a line connecting both
anterosuperior iliac spines and the superior
border of the symphysis (Fig. 4), which can
easily and reproducibly be palpated by the ra-
diology technician [16, 17]. Accordingly, the
cross-table view of the proximal femur is
taken with the leg internally rotated, with a
film-focus distance of 1.2 m, and with the
central beam directed to the inguinal fold
[18]. If these prerequisites of correct position-
ing of the patient and accurate radiographic
technique are not fulfilled, the radiographs
must be interpreted with caution.
A faux profile of Lequesne and de Sèze [19]
may be used for quantification of anterior over-
coverage but is rarely indicated for femoroac-
etabular impingement because it does not show
the relationship between the anterior and the
posterior acetabular rims. Rather, it is used to
assess the posteroinferior part of the hip joint to
detect the so-called contrecoup lesions in pin-
cer impingement described later.
To determine accurately the individual pel-
vic tilt of a patient, a strong lateral view of the
pelvis can be obtained (Fig. 5B). Correct in-
Fig. 3—Clinical tests to assess femoroacetabular impingement. Anterior impingement sign (left) is positive, with
painful forced internal rotation in 90º of flexion. In extreme forms, there is unavoidable passive external rotation of terpretation of pelvic tilt is crucial for accu-
hip during hip flexion (“Drehmann’s” sign, center). “Posterior impingement” sign is positive when there is painful rate description and radiographic assessment
forced external rotation in maximal extension (right). of individual hip parameters. A neutral tilt is
AJR:188, June 2007 1541

Tannast et al.
Fig. 4—Correct setting for anteroposterior and strong

lateral (left) pelvic radiography. Cross-table axial
radiograph of hip (right) is needed to visualize anatomy
of anterior femoral head–neck junction, which is not
visible on anteroposterior pelvic radiograph.
Fig. 5—27-year-old woman.

A, Bilateral “cross-over” sign is visible on this anteroposterior pelvic radiograph that
is analyzed with specifically developed software Hip2Norm (University of Bern,
Switzerland) for tilt and rotation correction of parameters of pelvic radiographs [17].
B, Strong lateral view shows pelvic inclination of 75º, representing anterior tilt of 15º
in relation to neutral inclination of 60º [20].
C, Computerized virtual correction to neutral orientation reveals normal hip
morphology.
C
defined with a pelvic inclination angle of 60º, The use of gonadal shielding is not particu- Pincer Impingement
which includes a horizontal line and a line larly recommended for the initial assessment of Pincer impingement is more common in
connecting the upper border of the symphysis the hip because it impedes correct interpretation middle-aged women, occurring at an average
and the sacral promontory [20] (Fig. 5). of the individual tilt and rotation described later. age of 40 years, and can occur with various
1542 AJR:188, June 2007

TABLE 1: Characteristics of the Two Types of Femoroacetabular Impingement

Criteria Pincer Impingement Cam Impingement
Cause Focal or general overcoverage Aspherical head
Mechanism Linear contact between overcovering rim and head–neck Jamming of aspherical head portion into acetabulum
junction
Sex distribution (M:F) 1:3 14:1

Average age (range) (y) 40 (40–57) 32 (21–51)
Typical location of cartilage damage Circumferential with contrecoup 11- to 3-o’clock position
Average depth of cartilage damage (mm) 4 11
Bladder extrophy Slipped capital femoral epiphysis
Proximal femoral focal deficiency Legg-Calvé-Perthes disease
Posttraumatic dysplasia Posttraumatic retrotorsion of femoral head
Chronic residual dysplasia of acetabulum Coxa vara
Associated disorders Legg-Calvé-Perthes disease Pistol-grip deformity
Slipped capital femoral epiphysis Head-tilt deformity
After acetabular reorientation procedures Post-slip deformity
Idiopathic retroversion Femoral retroversion
Growth abnormality of femoral epiphysis
Coxa profunda Pistol-grip deformity
Protrusio acetabuli CCD angle < 125°
Focal acetabular retroversion (figure-8 configuration) Horizontal growth plate sign
Radiographic signs on anteroposterior
Lateral center edge angle > 39°
radiographs
Reduced extrusion index
Acetabular index ≤ 0°
Posterior wall sign
Linear indentation sign Alpha angle > 50°
Radiographic signs on cross-table Femoral head–neck offset < 8 mm
radiographs Offset ratio < 0.18
Femoral retrotorsion
Herniation pits
Ossification of labrum
Appositional bone sign
Secondary changes
Os acetabuli
Posterior inferior joint space loss (on faux profile in pincer hips)
Late: classic signs of osteoarthritis
Note—CCD = centrum collum diaphyseal angle.
disorders (Table 1). Pincer impingement is of the acetabular fossa. A normal hip ap- quantified with the lateral center edge angle or
the result of overcoverage of the hip and can pears on an anteroposterior pelvic radio- the acetabular index [22]. The lateral center
lead to osteoarthritis [21]. Pincer impinge- graph with the acetabular fossa line lying edge angle is the angle formed by a vertical line
ment is also the result of a linear contact be- laterally to the ilioischial line (Fig. 6). A and a line connecting the femoral head center
tween the acetabular rim and the femoral coxa profunda is defined with the floor of with the lateral edge of the acetabulum. A nor-
head–neck junction due to general or focal ac- the fossa acetabuli touching or overlapping mal lateral center edge angle varies between
etabular overcoverage (Fig. 2). In contrast to the ilioischial line medially (Fig. 7). Protru- 25º (which defines a dysplasia) [23] and 39º
cam impingement, cartilage damage of the sio acetabuli occurs when the femoral head (which is an indicator for acetabular overcov-
acetabular cartilage is restricted in pincer hips is overlapping the ilioischial line medially erage) [24]. The acetabular index is the angle
to a small thin strip near the labrum that is (Fig. 8). Both forms relate to an increased formed by a horizontal line and a line connect-
more circumferentially located [7]. depth of the acetabuli; however, at this stage ing the medial point of the sclerotic zone with
no clear information exists that the two en- the lateral center of the acetabulum. In hips
General Acetabular Overcoverage tities are a continuation of each other. with coxa profunda or protrusio acetabuli, the
Normally, general acetabular overcover- Generally, a deep acetabulum is associated acetabular index (also called “acetabular roof
age is correlated with the radiologic depth with excessive acetabular coverage that can be angle”) is typically 0º or even negative.
AJR:188, June 2007 1543

Tannast et al.
Fig. 6—Schematic (left) and radiographic (right)

appearances of normal hip (detailed view of
anteroposterior pelvic radiograph) in 35-year-old man.
Acetabular fossa (F) is lateral to ilioischial line (IIL).
Acetabular index (AI) is positive, and femoral head (H)
is not entirely covered by acetabulum (E). Projected
anterior wall (AW) lies medially to posterior wall (PW),
which typically runs more or less through center of

femoral head. Extrusion index (E / [A + E]) is
approximately 25%. Lateral center edge (LCE) angle is
25–39º. Epiphyseal scar lies in femoral head circle
(arrows). A = covered portion of femoral head,
E = uncovered portion of femoral head.

presentations of coxa profunda (detailed view of
A' E' anteroposterior pelvic radiograph) in 29-year-old woman.
Acetabular fossa (F) is touching or overlapping ilioischial
line (IIL). Femoral head (H) is more covered, resulting in
AI' decreased femoral head extrusion index (E / [A + E]),
H neutral acetabular index (AI'), and increased lateral
center edge (LCE') angle. A' = covered portion of the
F femoral head, E' = uncovered portion of the femoral head.
LCE'
IIL
A" E"
AI"
H LCE"
F

IIL
presentations of protrusio acetabuli (detailed view of
anteroposterior pelvic radiograph) in 42-year-old
woman. Femoral head line (H) is crossing ilioischial line
(IIL). As a consequence, femoral head extrusion index
(E / [A + E]) is zero or even negative, acetabular index
(AI") is negative, and lateral center edge (LCE") angle
increases. F = acetabular fossa. A" = covered portion of
femoral head, E" = uncovered portion of femoral head.
Another parameter for quantification of however, to our knowledge no study has de- radiographs are not useful for reliable diagno-
femoral coverage is the femoral head extrusion fined a minimum extrusion. sis of a deep acetabulum.
index, which defines the percentage of femoral A pitfall: Formation of a pseudodeep ace-
head that is uncovered when a horizontal line is tabulum can be produced on an anteroposte- Focal Acetabular Overcoverage
drawn parallel to the interteardrop line [25]. A rior radiograph that is centered over the hip Focal overcoverage can occur in the anterior
normal extrusion index is less than 25% [26]; (Fig. 9). Because of this centering error, these or the posterior part of the acetabulum. Anterior
1544 AJR:188, June 2007

A B
Fig. 9—Influence of direction of center of X-ray beam on appearance of acetabular depth in 22-year-old man. Arrows show herniation pit caused by cam type of
femoroacetabular impingement. IIL = ilioischial line, AW = anterior wall, PW = posterior wall, F = fossa.
A, Section of anteroposterior pelvic radiograph shows regular acetabular configuration with acetabular fossa lying lateral to ilioischial line.
B, Hip radiograph centered over hip shows apparent coxa profunda. In addition, version of acetabulum seems to be larger with anterior wall being projected more medially.

presentations of focal anterior overcoverage of hip in
29-year-old woman. Acetabular retroversion is defined
as anterior wall (AW) being more lateral than posterior
wall (PW), whereas in normal hip anterior wall lies
more medially. This cranial acetabular retroversion
can also be described by figure-8 configuration.

presentations of too-prominent posterior wall (PW)
show posterior wall line running laterally to femoral
head center in 30-year-old man.
AJR:188, June 2007 1545

Tannast et al.
Fig. 12—Faux profile of To distinguish between a too-prominent ante-

25-year-old man with rior wall and a deficient posterior wall, the pos-
pincer impingement
shows posteroinferior terior wall must be depicted in more detail.
joint space narrowing Therefore, the “posterior wall” sign was intro-
(arrow) as result of duced as an indicator for a prominent posterior
recurrent subluxations,
wall. This can cause posterior impingement
which is unfavorable
prognostic sign. with reproducible pain in hip extension and ex-
ternal rotation (Fig. 3). In a normal hip, the vis-
ible outline of the posterior rim descends ap-
proximately through the center point of the
femoral head (Fig. 6). If the posterior line lies
laterally to the femoral center, a more prominent
posterior wall is present (Fig. 11). In contrast, a
deficient posterior wall has the posterior rim
medial to the femoral head center. A deficient
posterior wall is often correlated with acetabular
retroversion or dysplasia [27]; an excessive pos-
terior wall can often be seen in hips with coxa
profunda or protrusio acetabuli but can also oc-
cur as an isolated entity. Acetabular retroversion
can also be caused by acetabular reorientation
procedures if the configuration of the acetabular
rims is not taken into consideration [30, 31].
This persistent abutment in the anterior
part of the joint can lead to a slight sublux-
ation posteroinferiorly. The increased pres-
overcoverage is called “cranial acetabular line projected medially to the posterior wall line sure between the posteroinferior acetabulum
retroversion” or “anterior focal acetabular [16, 27–29] (Fig. 6). A focal overcoverage of and the posteromedial aspect of the femoral
retroversion” and causes anterior femoroac- the anterosuperior acetabulum causes a crani- head can cause chondral damage to the pos-
etabular impingement that can be reproduced ally retroverted acetabulum. This is defined teroinferior part of the acetabulum as a con-
clinically with painful flexion and internal rota- with the anterior rim line being lateral to the trecoup lesion, which occurs in approxi-
tion. By carefully tracing the anterior and pos- posterior rim in the cranial part of the acetabu- mately one third of pincer cases [3, 7, 32].
terior acetabular rims, different acetabular lum and crossing the latter in the distal part of The resulting loss of joint space can be visu-
configurations can be identified. A normal ac- the acetabulum. This figure-8 configuration is alized on a faux profile and is a bad prognos-
etabulum is anteverted and has the anterior rim called the “cross-over” sign (Fig. 10). tic sign (Fig. 12).
Fig. 13—Retroversion
sign can be missed if
central X-ray beam is not
directed correctly.
A, In this cadaveric pelvis
with wire marking
acetabular rims, cranial
acetabular retroversion
is visible on left side on
anteroposterior pelvic
radiograph. Center of
X-ray beam is marked
with radiopaque marker.
B, On anteroposterior hip
view, retroversion sign
disappears.
A B
1546 AJR:188, June 2007

A B
Fig. 14—Influence of individual pelvic orientation on appearance of acetabular rim.

A, Normal acetabular configuration is shown in this cadaveric pelvis with wire
marking acetabular rims. a = vertical distance between upper border of symphysis
and sacrococcygeal joint.
B, Increased pelvic tilt (visible on increased distance between symphysis and
sacrococcygeal joint, a’) leads to apparent retroversion of acetabular rim on both
sides. Arrows indicate apparent bilateral retroversion due to increased pelvic tilt.
C, Rotation to right (with consecutive increased horizontal distance between middle
of symphysis and sacrococcygeal joint, b (horizontal distance between mid of
symphysis and mid of sacrococcygeal joint) leads to apparent retroversion of right
hip and to pronounced anteversion of left hip. Arrow indicates creation of apparent
retroversion on right side due to rotation on right.
C
Regarding pitfalls, in certain hips, distin- cross-over sign can even be missed if only radiograph, the radiographs of extensively ro-
guishing between the two lines of the acetab- an anteroposterior radiograph of the hip is tated or tilted pelves can be calculated back
ular rim is difficult. As a helpful guideline, the available (Fig. 13). with recently developed software Hip2Norm
posterior rim line can always be readily iden- The appearance of acetabular morphology (University of Bern, Switzerland) to ensure a
tified when starting from the inferior edge of depends on the individual pelvic orientation, tilt and rotation independent of anatomically
the acetabulum. which can vary considerably in terms of tilt based interpretation of the acetabular mor-
An anteroposterior radiograph centered and rotation [33]. Increased pelvic tilt or a ro- phologic configuration [17] (Fig. 5). If ob-
over the hip is not usable for reliable diag- tation to the ipsilateral hip leads to a more tained, the lateral pelvic view must be taken
nosis of acetabular retroversion. This pro- pronounced retroversion sign and vice versa after the anteroposterior projection without
jection will imply a discrepancy in the ap- [16, 17, 34, 35] (Fig. 14). A neutral pelvic ro- motion of the patient and with the central
pearance of the acetabular rim compared tation is defined as the tip of the coccyx point- beam directed to the upper tip of the greater
with a standard pelvic radiograph, on which ing toward the midpoint of the superior aspect trochanter (Fig. 4).
the anterior rim will be displayed more of the symphysis pubis. As a general rule, a In addition to acetabular pathomorpholo-
prominently because it lies closer to the neutral pelvic tilt is defined as the distance of gies, pincer impingement can also be caused
X-ray beam source [17, 29]. Therefore, ac- 3.2 cm between the upper border of the sym- by excessive hip motion in patients in whom no
etabular version is generally overestimated physis and the midportion of the sacrococ- obvious acetabular disorder is present. It oc-
when interpreting an anteroposterior radio- cygeal joint for men, and 4.7 cm for women curs typically in hypermobile young women
graph centered over the hip. In addition, a [16]. With the help of one additional lateral (e.g., ballet dancers).
AJR:188, June 2007 1547

Tannast et al.
A
Fig. 15—Cam impingements.
A, Pistol-grip deformity with abnormal extension of epiphyseal scar (arrows) in
19-year-old man.
B, Axial view of normal hip with normal offset (OS) and normal alpha angle (α < 50º)
in 32-year-old man.
C, Decreased femoral head–neck offset (OS') with consecutive increased alpha
angle (α') in 26-year-old man.
C
Cam Impingement Cam impingement can be caused by an os- Quantification of the amount of asphericity
Cam impingement is more common in seous bump on the femoral head–neck junc- can be accomplished by the angle α, the femo-
young men, occurring at an average age of 32 tion or by a retroverted femoral neck or head. ral offset, or the offset ratio [37]. Angle α is the
years. Cam impingement is the femoral cause Osseous bumps are typically located either angle between the femoral neck axis and a line
of femoroacetabular impingement and is in the lateral (so-called pistol grip, seen connecting the head center with the point of be-
caused by an aspherical shape of the femoral on an anteroposterior pelvic radiograph ginning asphericity of the head–neck contour
head where the nonspherical portion is jammed [Fig. 15A]) or in the anterosuperior (seen on (Fig. 15). It can be measured on radiographs.
into the acetabulum as a result of several known an axial cross-table view of the proximal fe- An angle exceeding 50º is an indicator of an ab-
causes or idiopathically [6, 36, 37] (Fig. 2 and mur [Figs. 15B and 15C]) portion of the normally shaped femoral head–neck contour.
Table 1). These osseous bumps lead to a de- femoral head–neck junction (Figs. 15B and Another parameter for quantification of
creased femoral head–neck offset, which is de- 15C). A pistol-grip deformity is character- cam impingement is the anterior offset, which
fined by the distance between the widest diam- ized on radiographs by flattening of the usu- is defined as the difference in radius between
eter of the femoral head and the most prominent ally concave surface of the lateral aspect of the anterior femoral head and the anterior fem-
part of the femoral neck (Fig. 15). The recur- the femoral head due to an abnormal exten- oral neck on a cross-table axial view of the
rent irritation leads to an abrasion of the acetab- sion of the more horizontally oriented femo- proximal femur (Fig. 15). In asymptomatic
ular cartilage or its avulsion from the subchon- ral epiphysis [39–42] (Fig. 15). hips, the anterior offset is 11.6 ± 0.7 mm; hips
dral bone [38]. The cartilage area involved in Cam impingement is usually caused by a with cam impingement have a decreased ante-
cam impingement is much larger than pure pin- primary osseous variant of the head–neck rior offset of 7.2 ± 0.7 mm [18]. As a general
cer impingement and may be associated with junction that is considered to be caused by a rule for clinical practice, an anterior offset less
large areas of cartilage delamination or fissur- growth abnormality of the capital femoral ep- than 10 mm is a strong indicator for cam im-
ing. However, in both mechanisms, although iphysis [42], but it can also be the result of pingement. In addition, the so-called offset ra-
there is significant and irreversible prearthritic several known causes, such as a subclinical tio can be calculated, which is defined as the
damage of the cartilage, there is no joint space slipped capital femoral epiphysis [43–45] or ratio between the anterior offset and the diam-
narrowing because only the quality of the carti- Legg-Calvé-Perthes disease [4, 46], or it can eter of the head. The offset ratio is 0.21 ± 0.03
lage, and not its diameter, is impaired in the occur after femoral neck fractures [2, 47]; it in asymptomatic patients and 0.13 ± 0.05 in
early stage of the disease. may also be idiopathic (Table 1). hips with cam impingement.
1548 AJR:188, June 2007

A B
Fig. 16—Secondary radiographic signs of femoroacetabular impingement.
A, Recurrent impingement can lead to ossification of labral basis (white arrow) and to osseous apposition of acetabular rim, which is visible as double contour (black arrows)
in 45-year-old woman.
B, Because of abnormal stress in impinging hips, prominent acetabular bone fragment can even be separated from adjacent bone margin (os acetabuli, arrow) in 36-year-
old man with pistol-grip deformity.
Another cause for cam impingement is sion during subtle subluxation of the femoral Hips with femoroacetabular impingement
femoral retrotorsion, which can occur as a pri- head. This bad prognostic sign is best seen on have a significantly higher prevalence of herni-
mary entity [48] or posttraumatically after a faux profile of the hip or, if available, on ation pits, which are thought to be benign and
healed femoral neck fractures [47]. Femoral MRI (Fig. 12). incidental and the cause of which was not
retrotorsion can be calculated reliably only on clearly understood [51]. Herniation pits are ra-
CT scans involving the proximal and distal Secondary Radiographic diolucencies surrounded by a sclerotic margin
parts of the femur [49]. In addition, a coxa Changes in Hips that are typically located in the anterior proxi-
vara (defined by a centrum collum diaphyseal Unrecognized femoroacetabular im- mal superior quadrant of the femoral neck and
angle [CCD] of less than 125º) has been rec- pingement leads to recurrent irritation of the occur in some 33% of patients; they range in
ognized as a cause of cam impingement [50]. acetabular labrum, which is the first struc- size from 3 to 15 mm (mean, 5 mm) [52]. This
A pitfall: In the initial phase of the disease, ture involved and which is seen in both types previously described location corresponds
these entities are anatomic abnormalities and of impingement. It leads to a reactive ossifi- well to the typical location where the femoro-
do not represent classic osteophytes. Classic cation, particularly of the labral basis [8] acetabular impingement occurs. Therefore,
osteophytes occur in an advanced stage of the (Fig. 16). In an advanced stage of the dis- hips with these juxtaarticular cysts should be
disease when the cartilage damage already ease, additional reactive bone apposition at considered a joint at risk for femoroacetabular
has taken place. Osteophyte formation can the osseous rim leads to further deepening impingement rather than one with a benign le-
lead to a worsening of femoroacetabular im- of the acetabulum, thereby increasing the sion, but herniation pits are not always associ-
pingement, an increase of the overcoverage impingement problem, which can also be ated with symptomatic impingement.
for pincer hips, or a further loss of femoral seen as a double contour of the acetabular
head–neck offset. Through careful evaluation rim (Fig. 16). Because of the abnormal General Pearls and Pitfalls
of the radiographs, the original acetabular rim stress in impinging hips, the prominent ace- of Femoroacetabular
can be identified. Occasionally, on the femo- tabular bone fragment can even be separated Impingement Imaging
ral side at the head–neck junction, a linear in- from the adjacent bone margin. This os ace- Systemic disorders with hip joint involve-
dentation may be observed in hips with pincer tabulum is an acetabular rim fracture, pre- ment may superficially mimic femoroacetab-
impingement and a cortical thickening sumed to be a stress or impingement frac- ular impingement; these include ankylosing
(Fig. 17). In the end stage of pincer impinge- ture, resulting from a constant jamming of spondylitis, diffuse idiopathic skeletal hyper-
ment, posteroinferior cartilage abrasion oc- the femoral head against the acetabulum ostosis (DISH), and congenital hip dysplasia.
curs, which is the result of the contrecoup le- [27] (Fig. 16). However, these are usually easy to distinguish
AJR:188, June 2007 1549

Tannast et al.
A B
Fig. 17—Pincer hips in 37-year-old woman.
A and B, In pincer hips, corresponding linear indentation often occurs on femoral side (black arrows) with reactive cortical thickening (white arrows), which can be seen on
conventional radiograph (A) and on MR arthrogram with intraarticular contrast agent (B).
from systemic disorders with hip joint in- standard remains the patient’s pain and not this circle until the femoral head expansion is
volvement by reviewing the sacroiliac joints the imaging findings alone. However, because met. If there is any bone beyond this circle,
that will be fused or pathologic with anky- the prognosis of the hip joint is significantly then cam impingement is likely. These circles
losing spondylitis and other seronegative better if the intraarticular impingement is can be drawn on both the frontal and axial ra-
spondyloarthropathies and the spine for ante- eliminated as early as possible, surgical re- diographs (Fig. 15).
rior longitudinal ligament calcification with construction of the hip joint is recommended
DISH. Congenital hip dysplasia presenting in as soon as the first symptoms occur [4, 38]. Treatment of Femoroacetabular
adulthood is characterized by a lack of ace- A suboptimal or faulty radiographic tech- Impingement
tabular coverage and by lateral proximal fem- nique of the pelvis and hip joint may over- Surgical treatment of femoroacetabular
oral head subluxation and is more commonly or underestimate or falsely diagnose femo- impingement focuses on improving the clear-
associated with large labral ganglion [53]. roacetabular impingement. In addition to ance for hip motion and alleviation of femoral
Rarely, patients with femoroacetabular im- first reviewing for overall symmetry of the abutment against the acetabular rim. This in-
pingement may have additional disorders such hip joints on the frontal radiograph, in a cludes basically the surgical resection of the
as hydroxyapatite deposition in the acetabular busy clinical setting with no strong lateral impinging cause, by trimming the acetabular
labrum; however, this calcification has usually view obtained, brief review of the location rim or the femoral head–neck offset either via
resolved on follow-up radiographs at 6 weeks. of the sacrococcygeal joint in relation to the a surgical hip dislocation [3, 12, 54] or arthro-
More commonly, in the younger adolescent superior aspect of the symphysis pubis is scopically [55], or, rarely, by the reorientation
age group, there may be associated enthesopa- helpful. If the sacrococcygeal joint is within of a retroverted acetabulum via a reversed pe-
thy of the greater trochanter associated with approximately 3.2 cm of the symphysis for riacetabular osteotomy [28]. Mid-term results
gluteal tendon overuse, as evident by bone men or 4.7 cm for women, then the pelvic from these procedures are promising [4, 38].
spurring of the greater trochanter. tilt should be largely neutral. Suboptimal
Femoroacetabular impingement is often technique may be minimized by obtaining Conclusion
bilateral but may present asynchronously. Al- radiographs as described in this article or by In conclusion, two main forms of femoro-
though symptomatic presentation may be de- using a computer-assisted program that cor- acetabular impingement—pincer and cam—
layed on one side, reviewing both hip joints is rects for malpositioning [17] (Fig. 5). Accu- occur in young active individuals presenting
recommended. In patients with typical femo- rate angles, measurements, and ratios are with hip pain, although most patients will
roacetabular impingement, radiographic fea- also possible with such a tool, as is accurate have a combination of both impingement
tures may be asymptomatic as a result of lack preoperative planning. types. The radiographic technique and typical
of activity or of being at an early stage in the Another way of reviewing the radiographs findings have been presented. MRI and MR
development of femoroacetabular impinge- for femoroacetabular impingement in a busy arthrography are important for further evalu-
ment. Although there are characteristic imag- clinical setting is to use the PACS tool to pre- ation of the osseous and soft-tissue abnormal-
ing findings of femoroacetabular impinge- scribe a circle, beginning centered on the cen- ities of impingement; these will be presented
ment, at this stage of knowledge, the gold tral point of the femoral head, and to enlarge in a future article.
1550 AJR:188, June 2007

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F O R YO U R I N F O R M AT I O N
This article is available for CME credit. See www.arrs.org for more information.
1552 AJR:188, June 2007

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Femoral Acetabular Impingement Important

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Tannast et al.

emoroacetabular impingement (pre- lar impingement do not have classic radio-

F viously also called “acetabular rim

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Fig. 1—Flowchart shows Femoroacetabular Impingement

AJR:188, June 2007 1541

Fig. 4—Correct setting for anteroposterior and strong

Fig. 5—27-year-old woman.

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TABLE 1: Characteristics of the Two Types of Femoroacetabular Impingement

Sex distribution (M:F) 1:3 14:1

AJR:188, June 2007 1543

Fig. 6—Schematic (left) and radiographic (right)

which typically runs more or less through center of

Fig. 7—Schematic (left) and radiographic (right)

Fig. 8—Schematic (left) and radiographic (right)

1544 AJR:188, June 2007

Fig. 10—Schematic (left) and radiographic (right)

Fig. 11—Schematic (left) and radiographic (right)

AJR:188, June 2007 1545

Fig. 12—Faux profile of To distinguish between a too-prominent ante-

1546 AJR:188, June 2007

Fig. 14—Influence of individual pelvic orientation on appearance of acetabular rim.

AJR:188, June 2007 1547

1548 AJR:188, June 2007

AJR:188, June 2007 1549

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AJR:188, June 2007 1551

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Surgery 36:5, 1323-1334. [Crossref]

Cam Morphology in Females with Femoroacetabular Impingement. Frontiers in Surgery 2. . [Crossref]

HIP International 25:3, 258-263. [Crossref]

Acetabular Retroversion. JBJS Essential Surgical Techniques 5:1, e1. [Crossref]

Physical Therapy 44:11, 890-898. [Crossref]

Traumatology 14:3, 201-206. [Crossref]

Femoroacetabular Impingement: CT Findings of Features Resembling Femoroacetabular Impingement in a Young Population

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