Femoroacetabular Impingement/FAI

Dr Kishor Bista
3rd year Resident
Moderator: Dr Subash Lal
Karn
Outline :
Background
Definition
Pathology
Clinical features
Investigations
Treatment
 Background
FAI as a cause of hip OA is relatively new

Pathogenesis has been elaborated significantly only

in the last 10–15 years.

Majority of ‘idiopathic ‘ causes of OA now thought to

be due to
Mild dysplasia
FAI
Other subtle morphological abnormalities
Cross-sectional imaging: Kapser
Govsing etal2010
Malformation :71% men, 36%
women
FAI most common
Definition
A subtle mechanical abnormality in either or both of the proximal femur and
acetabulum leading to abnormal contact between femoral neck and acetabulum
during movement.
Mechanical cause of Hip OA

Types
1 . Cam
2. Pincer
3. Combined : Most common type of FAI
Cam

Pincer
Cam FAI

Pathology :
Bony thickening at femoral head-neck junction
Loss of femoral head sphericity
Jamming of the femoral neck against the front of the acetabulum.
Associated disorders : SUFE, Malunion # NOF/head
Structure of primary damage : Acetabular cartilage
Secondary change : Labral degeneration
Progression : rapid
Pincer FAI
Impact during hip
flexion
Pathology :
Anomaly in acetabular structure
Over-coverage of the femoral head Damage to labrum
Impingement of the femoral neck on the anterior
acetabulum with flexion .
Cartilage
Delamination

OA
Associated disorders: Global overcoverage (Coxa profunda/protrusion) or Focal
anterior coverage ( by anterior part of the acetabular rim of acetabular
retroversion)
Structure of primary damage : Labrum
Secondary change : cartilage (contre-coup lesion)
Progression : Slow
Pattern of cartilage damage

Counter coup
lesion

Pincer FAI Cam FAI

Clinical features:

Initially Groin pain

Decreased range of movement
Activity related pain
Can be sharp & catching ,worse with
sitting and deep flexion.
Pincer type FAI : Female over 40 years
Cam type FAI : Male /25-30 years
Late stage : established OA
O/E :
Anterior Impingement test/FADIR
 Radiological Investigation

Cam type signs:

Characteristic bump
Pistol grip deformity by Stulberg
Tilt deformity by Murray
Modified Dunn view
Displays anterosuperior head-neck junction
 Alpha angle

Lateral view:
Normal:42 degree
>50-55degree: head neck offset
deformity suggestive of Cam FAI
Head neck offset ratio:
Distance between 2nd & 3rd line
Diameter of femoral head

Ratio <0.17: Cam deformity

Pincer Type Signs
Cross-over sign

Normal Pincer FAI

 Ischial spine sign
Posterior wall sign
Lateral central edge angle of Wiberg
Normal: 25-40
Borderline dysplasia:20-24
Dysplasia: <20
Lateral overcoverage >40
Anterior center edge (ACE) angle
of Lequesne
Measured on False profile view
Normal ACE angle :20 degrees
Undercoverage<20 degree
Tonnis angle
Normal:0 and 10 degrees.
hip dysplasia: >10 degree.
Overcoverage:< 0 degree.
Coxa profunda
Beta angle:
Beta angle < 30 degree:
Impingement morphology: C/P/M
MRI arthrogram:
Sensetive and specific for detecting labral and chondral lesion
Treatment:

Non-operative treatment:?
Symptom management and modification of activity .
Involving physical therapy
Muscle stretching
Hip traction
Operative treatment:
Indication : If pain persist
Principle : Resection of the ‘impingement lesion’ : osteo-chondroplasty
Joint preservation of the hip can be performed either Open or Arthroscopic
surgery, combined.
1. Arthroscopic procedure: minor or localized structural abnormality
2. Open procedure :Ganz et al. Surgical hip dislocation
3. Combined hip arthroscopy and limited open osteochondroplasty: Clohisy and
Mcclure
In cam-type FAI :
Recontouring of the head-neck junction: re-establish the sphericity
In pincer-type :
Rim resection for focal anterior over-coverage .
Associated labral tears are repaired
Realignment osteotomy of acetabulum :PAO
Surgical hip dislocation/ Ganz trochanteric
osteotomy
1. Excellent exposure
2. Tt of severe deformities
3. Preserves femoral head BS
4. Soft tissue repair
FAI – surgery Open surgical dislocation of the hip performed via a Ganz osteotomy.
(a) Loss of the head-neck junction. (b) Recreation of the anterior offset
by bone resection (osteochondroplasty).
Ribas et al mini-open direct anterior approach

Smith-Petersen interval
 Periacetabular osteotomy
Indication:
Pincer-type impingement caused by global
acetabular retroversion
References
Cambell operative orthopaedic 13th edi
Apley’s & solomon system of orthopaedic trauma 10th edi
Orthobullets 2017
Thank you