Femoroacetabular Impingement A Cause For13 231106 161042

CLINICAL ORTHOPAEDICS AND RELATED RESEARCH
Number 417, pp. 112–120

B 2003 Lippincott Williams & Wilkins, Inc.
Femoroacetabular Impingement
Downloaded from http://journals.lww.com/clinorthop by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCy
A Cause for Osteoarthritis of the Hip

wCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8K2+Ya6H515kE= on 11/06/2023
Reinhold Ganz, MD*; Javad Parvizi, MD**; Martin Beck, MD*;

Michael Leunig, MD*; Hubert Nötzli, MD*; and Klaus A. Siebenrock, MD*
A multitude of factors including biochemical, ge- Osteoarthritis is a disorder of diverse etiologies,

netic, and acquired abnormalities may contribute which commonly can affect the hip.5,11,24 A
to osteoarthritis of the hip. Although the patho- Workshop on Etiopathogenesis of Osteoarthritis
mechanism of the degenerative process affecting (OA) provided a definition and a classification
the dysplastic hip is well understood, the exact
system for OA that includes a category of
pathogenesis for idiopathic osteoarthritis has not
patients with idiopathic osteoarthritis, for whom
been established. Based on clinical experience, with
more than 600 surgical dislocations of the hip, no etiologic factors can be determined.6
allowing in situ inspection of the damage pattern The biomechanical principles for develop-
and the dynamic proof of its origin, we propose ment of OA of the hip generally are based on the
femoroacetabular impingement as a mechanism calculations of force transmission in that carti-
for the development of early osteoarthritis for most lage degeneration is thought to be initiated by
nondysplastic hips. The concept focuses more on concentric or eccentric overload.1,22 A malor-
motion than on axial loading of the hip. Distinct iented articular surface with decreased contact
clinical, radiographic, and intraoperative parame- area in circumstances such as developmental
ters can be used to confirm the diagnosis of this dysplasia of the hip typically leads to excessive
entity with timely delivery of treatment. Surgical
and eccentric loading of the anterosuperior por-
treatment of femoroacetabular impingement focus-
tion and subsequently promotes the development
es on improving the clearance for hip motion and
alleviation of femoral abutment against the acetab- of early OA of the hip.18,19,27 This widely ac-
ular rim. It is proposed that early surgical interven- cepted theory implicating axial overload for the
tion for treatment of femoroacetabular impingement, onset of OA of the hip fails to provide a sat-
besides providing relief of symptoms, may deceler- isfactory explanation for development of arthritis
ate the progression of the degenerative process for in groups of often young patients with apparently
this group of young patients. normal skeletal structures and intraarticular
pressures.
Based on our clinical experience spanning
From the *Department of Orthopedic Surgery, University of more than a decade, we have evidence that in
Berne, Inselspital, Berne, Switzerland; **Rothman Institute, many cases of idiopathic arthritis, predisposing
Thomas Jefferson University, Philadelphia, PA.
factors, in the form of femoroacetabular impinge-
Reprint requests to Reinhold Ganz, MD, Department of ment, are present that are not appreciated readily
Orthopedic Surgery, Inselspital, CH-3010 Berne, Switzer-
land. Phone: 031 632 2111; Fax: 031 632 3600; E-mail: using the traditional diagnostic modalities.3,7,12,21
reinhold.ganz@insel.ch. The theory implies that in certain aberrant
DOI: 10.1097/01.blo.0000096804.78689.c2 morphologic features of the hip, abnormal contact
111
Copyr ight © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Clinical Orthopaedics
112 Ganz et al and Related Research
between the proximal femur and the acetabular acetabular rim. Forceful additional internal ro-
rim that occurs during terminal motion of the hip, tation induces shearing forces at the labrum and
leads to lesions of the acetabular labrum and/or the creating a sharp pain when there is a chondral
adjacent acetabular cartilage. The phenomenon is lesion, a labral lesion, or both.16 Occasionally,
more common in young and physically active posteroinferior impingement also can occur. The
adults. The early chondral and labral lesions provocative test to elicit the latter type of im-
continue to progress and result in degenerative pingement is done by having the patient lie
disease of the joint if the underlying cause of supine on the edge of the bed and have the legs
impingement is not addressed.7,13 A previous hang free from the end of the bed, to create
publication from this institution provided evi- extension. External rotation in extension giving
dence for a type of femoroacetabular impingement rise to severe deep seated groin pain is indicative
to exist.12 of posteroinferior impingement. A positive im-
We describe the clinical presentation, radio- pingement test has been correlated closely to
graphic findings, the mechanism, and the distinct acetabular rim lesions as seen on specific modern
types of femoroacetabular impingement. Further- MRI arthrograms of the hip.15
more, the nature of the surgical procedures used
at our institution for the treatment of femoroace-
tabular impingement also will be outlined. RADIOGRAPHIC ASSESSMENT
An orthograde AP radiograph taken with the

CLINICAL PRESENTATION patient standing and a lateral radiograph of
the hip routinely are taken for all patients with
History the symptoms suggestive of femoroacetabular
Femoroacetabular impingement usually presents impingement. The optimal AP radiograph is
in active young adults with slow onset of groin taken when the coccyx points toward the sym-
pain that often starts after a minor trauma. During physis pubis with a distance of 1 to 2 cm between
the initial stages of the disease, the pain is inter- them. The radiographs often appear normal at
mittent and may be exacerbated by excessive first. However, on detailed review some abnor-
demand on the hip such as athletic activities or malities may become apparent including the
prolonged walking. The pain often is present presence of a bony prominence usually in the
after sitting for a prolonged period. Based on the anterolateral head and neck junction that is
presence of normal radiographs of the hips, these seen best on the lateral radiographs, reduced
patients sometimes are subjected to extensive offset of the femoral neck and head junction,
diagnostic workup and inappropriate surgical and changes on the acetabular rim such as os
therapeutic modalities including laparoscopy, acetabuli or double-line that is seen with rim
laparotomy, knee arthroscopy, lumbar spine de- ossification. Close scrutiny of the femoral neck
compression, and inguinal hernia repair. may reveal the presence of herniation pits,which
we postulate, are indicative of impingement.
Examination Morphologic changes affecting the acetabulum
Examination of the hip often reveals limitation of and/or the proximal femur such as retroversion,
motion particularly the internal rotation and ad- relative anterior over coverage, coxa profunda,9
duction in flexion. The impingement test almost protrusio acetabuli, coxa vara, extreme coxa
always is positive. This test is done with the valga, or occasionally subtle dysplasia only may
patient supine, the hip is rotated internally as it is become apparent on systematic examination of
flexed passively to approximately 908 and ad- the plain radiographs. We routinely request radial
ducted. Flexion and adduction leads to the sequence MRI arthrograms, done under a well-
approximation of the femoral neck and the established protocol and leading to very high
quality images, to observe the labrum and the

acetabular cartilage.15,30 Magnetic resonance
arthrograms also are capable of detecting or
confirming nonsphericity of the femoral head,
low offset of the neck, herniation pit, or os-

sification of the rim all resulting from impinge-
ment. Magnetic resonance arthrograms are very

sensitive and specific for detecting labral and
chondral lesions but have limitations for detect-
ing undetached chondral separations.30
MECHANISM OF FEMOROACETABULAR
IMPINGEMENT
Femoroacetabular impingement is a condition of

abnormal contact that may arise as a result of
either abnormal morphologic features involving
the proximal femur and/or the acetabulum or it
may occur in patients, with otherwise normal or
near-normal anatomic structure of the hip, who
experience impingement as a result of subject-
ing the hip to excessive and supraphysiologic
ROM. Often a combination of factors, including
the presence of aforementioned causes may lead
to femoroacetabular impingement. In patients
with morphologic features of the acetabulum
and/or the femoral neck, less motion is required
before abutment around the hip occurs. Unlike
a hip with a prosthesis, the native hip is under
stricter constraint, and therefore cannot easily
escape the detrimental effects of any contact or
shearing forces.
Fig 1A–B. A schematic presentation shows the
mechanism for cam and pincer impingement.
TYPES OF FEMOROACETABULAR (A) Cam impingement shows the nonspherical
IMPINGEMENT portion of the femoral head abutting against
the acetabular rim during hip flexion leading
Based on the pattern and the various stages of to chondral abrasion and labral detachment.
(B) Pincer impingement shows the linear contact
chondral and labral injuries observed in situ between the acetabular rim and the femoral head-
during surgical dislocation of the hip, two dis- neck junction. The femoral head may have normal
tinct types of femoroacetabular impingement morphologic features and the impingement is the
could be distinguished. result of acetabular abnormality. The first struc-
The first or cam impingement is caused by ture to fail in this situation is the acetabular
labrum. The persistent anterior abutment with
jamming of an abnormal femoral head with in- chronic leverage of the head in the acetabulum
creasing radius into the acetabulum during force- may result in chondral injury in the posteroinferior
ful motion, especially flexion.12,21 (Fig 1A). The acetabulum.
resulting shear forces produce outside-in abra- often is anterior, with chronic leverage of the
sion of the acetabular cartilage and/or its avulsion head in the acetabulum can result in chondral
from the labrum and the subchondral bone in a injury in the ‘contre-coup’ region of the poster-
rather constant anterosuperior rim area. Chondral oinferior acetabulum (Fig 1B).
avulsion in turn leads to tear or detachment of the Chondral lesions in pincer impingement often
principally uninvolved labrum. are limited to a small rim area and therefore are
The second or pincer impingement is the re- more benign. This is in contrast to deep chon-
sult of linear contact between the acetabular rim dral lesions and/or extensive labral tears that are
and the femoral head-neck junction (Fig 1B). seen with cam impingement (Fig 2). Pincer im-
The femoral head may have normal morphologic pingement is seen more frequently in middle-
features and the abutment is the result of acetab- aged women with a desire for athletic activites
ular abnormality, often a general (coxa profunda) (Fig 3). Cam impingement, however, is more
or local anterior over coverage (acetabular retro- common in young and athletic males.
version). The first structure to fail in this situation
is the acetabular labrum. Continued impact of SURGICAL TREATMENT
abutment results in degeneration of the labrum
with intrasubstance ganglion formation, or os- The surgical approach for treatment of femoro-
sification of the rim leading to additional deep- acetabular impingement was described by Ganz
ening of the acetabulum and worsening of the et al.7 Briefly, this involves placement of the
over coverage. The persistent abutment, which patient in the lateral decubitus position. Using a
Fig 2A–C. (A) Femoroacetabular impingement is

shown in a 34-year-old man with an apparently
mormal AP radiograph. (B) The nonspherical
femoral head leading to reduced offset at the
neck and predisposition to cam-type impingement
is visible on the lateral radiograph. (C) The MRI
scan confirmed the labral tear and chondral injury
resulting from Impingement.
Number 417
December, 2003 Femoroacetabular Impingement 115
Fig 3A–C. The (A) AP and (B) lateral radio-

graphs of the hip in a 42-year-old woman show
global acetabular over coverage (coxa profunda)
resulting in femoroacetabular impingement of
the pincer type. The AP radiograph also shows
cranial retroversion of the acetabulum. (C) The
MRI scan shows the labral destruction and a
secondary ossicle on the femoral neck that
resulted from linear contact between the femoral
neck and the acetabular rim during flexion.
trochanteric flip approach, the hip is exposed main blood supply of the femoral head can be
anteriorly and dislocated in the same direction, seen entering the superior portion of the neck and
while respecting the integrity of the external are carefully protected. For pincer impingement,
rotator muscles including the piriformis. This this includes reducing the anterior over coverage
allows full protection of the vascular supply of by excising the bony prominence at the rim or
the femoral head.8 After doing a Z-shaped cap- poor mans periacetabular osteotomy. The artic-
sulotomy, the hip is exposed and examined in ular cartilage covering the acetabular rim in the
detail. The surgical dislocation of the joint pro- area of the over coverage often is soft and
vides a full 3608 view of the femoral head and occasionally is detached. Using a nerve hook, the
the acetabulum for inspection. The site of im- cartilage may be rolled like a slack carpet on the
pingement is identified and the labrum and ace- floor. The torn or degenerate area of the labrum
tabular cartilage are checked for the presence of also is excised and the remainder of the labrum, if
any lesions. The surgical treatment comprises substantial, is reattached to the rim using suture
mainly removing any nonspherical portion of the anchors. Excision osteoplasty involving removal
head, thereby improving the neck offset and of the bony prominence in the extraarticular
subsequent clearance. Femoral neck osteoplasty portion of the femoral head also is done to in-
particularly is an important part of alleviating crease the femoral neck offset by creating a better
cam impingement. During osteoplasty of the waist at the head and neck junction. After com-
femoral neck, the retinacular vessels that are the pletion of the femoral and acetabular osteoplasty,
the hip is reduced and checked for impingement- derangement led to reduced clearance of the
free ROM. Excision of the excessive bone is joint and detectable abutment of the metaphy-
repeated if any residual impingement is detected. sis against the acetabular rim in patients with
Trochanteric advancement, femoral neck or SCFE.14 Depending on the stage of presentation,
intertrochanteric osteotomy, whenever is deemed chondral and labral injuries also were observed
necessary, is done to further improve clearance in patients with SCFE. A similar situation also is
and alleviate extraarticular impingement. present after femoral neck fracture, when the
femoral head is fixed in retrotilt.4
DISCUSSION Other, although not all inclusive, possible
disease processes resulting in morphologic de-
The concept of abnormal morphologic features rangement around the hip includes residual
around the hip leading to OA of that joint is not childhood diseases such as Perthes, and prior
novel. Stulberg et al28 reported on an abnormal surgical interventions such as femoral osteoto-
head-neck relationship on AP radiographs of mies. In our series of patients having surgical
their patients presenting with idiopathic arthritis. treatment for femoroacetabular impingement, we
They coined the term pistol grip deformity have been able to identify a subgroup of patients
to describe the radiologic appearance of this with prior periacetabular or intertrochanteric
morphologic abnormality but did not elucidate osteotomy in whom impingement was a direct
the mechanism responsible for the deformity. result of reduced joint clearance.20 Although
Other authors also have alluded to an abnor- detailed analysis of the outcome of surgical
mal anatomic relationship between the femo- intervention still is ongoing, the preliminary
ral head and neck as a possible cause for results indicate that surgical dislocation of the hip
OA.5,19,23,27,29 The majority of patients with and improvement of the head and neck offset was
femoroacetabular anomalies lack a clear history successful in addressing these patients’ symp-
of hip disease. Therefore, as suggested by some toms arising from the underlying impingement. It
authors, the morphologic abnormalities around therefore is imperative that the goal of improving
the hip in these patients are most likely the joint congruity and coverage, by doing osteoto-
result of a subtle developmental abnormality mies around the hip, is not achieved at the
such as coxa profunda,9 retroversion,25 or expense of reducing clearance and creating sub-
subclinical epiphyseal slip or displacement.10 sequent femoroacetabular impingement.
Several investigators have implicated sub- Various conditions affecting the acetabulum
clinical displacement of the femoral epiphysis as also can lead to morphologic changes predispos-
a risk factor for OA and have proposed the term ing the hip to impingement. Some of the con-
head-tilt or post-slip to describe the deformity ditions observed to cause femoroacetabular
resulting from mild slips.10,12,19,28 In one study impingement include acetabular retroversion,
using a three-dimensional volume computer coxa profunda, protrusio acetabuli, and posttrau-
model, Rab23 showed that considerable anterior matic deformities. Retroversion of the acetab-
metaphyseal impingement occurred during walk- ulum has been described as a posteriorly
ing and sitting in patients with slipped capital orientated acetabular opening with reference to
femoral epiphysis (SCFE). Abutment of the me- the sagittal plane.25 A retroverted acetabulum
taphysis against the acetabular rim was thought may occur as part of more complex acetabular
to be responsible for an increase in the intraar- developmental deformities,19 or it may be seen as
ticular pressures, and ultimately lead to degen- an isolated entity.2 Retroversion results in a
erative changes in the joint.23 prominent anterolateral acetabular edge, creating
The association between SCFE and femoro- an obstacle for flexion and internal rotation and
acetabular impingement has been confirmed in in turn predisposes the hip to femoroacetabular
a clinical study from our institution.14 Anatomic impingement. This situation is made worse if the
Number 417
prominent acetabular edge impinges against a version and mean head-neck offset in the anterior
proximal femur with a low head and neck offset aspect of the femoral neck was seen in patients
such as seen in hips with a pistol grip defor- presenting with impingement when compared
mity.11,28 Symptomatic impingement resulting with a group of age-matched and gender-
from underlying acetabular retroversion has been matched control subjects.12 Subsequent studies,
treated successfully with reverse periacetabular using standardized MRI, have confirmed that
osteotomy in a group of 26 patients from our hips of patients with symptomatic impingement
institution.26 Femoroacetabular impingement have significantly less concavity at the femoral
that was alleviated by removing the relative an- head-neck junction, when compared with nor-
terior over coverage could be confirmed in all mal hips.21
patients. Labral and chondral lesions in the an- Cam impingement results in deep chondral
terosuperior region of the acetabulum resulting injuries and subsequent labral detachment. Two
from the repetitive trauma of impingement were sets of observations made during surgical dis-
observed in more than 1/2 of the patients in the location of the hip have furnished the evidence in
aforementioned series, which may explain the support of chondral injury leading to labral tear
association of acetabular retroversion with de- and not the reverse as suggested by some sur-
velopment of OA.29 geons doing arthroscopic examination of the
Coxa profunda and protrusio acetabuli, by hip.17 First, all labral tears or detachments occur
increasing the relative depth of the acetabulum at the articular margin and not the capsular
also can result in femoroacetabular impinge- margin. The other observation is that chondral
ment.9,13 One unpublished study from our injuries without labral tears frequently are seen at
institution detected a high incidence of femo- the early stages of the impingement process. We
roacetabular impingement in patients with coxa think that solitary labral tears arising from an
profunda when compared with a group of acute traumatic event is rare. Labral tears not
patients with normal and asymptomatic hips. associated with chondral injuries only are ob-
This finding is intuitive in that deepening of the served in patients with early pincer impingement.
socket results in a relative decrease of the femoral Labral tears, particularly in the anterosuperior
neck, a decrease in the neck to head ratio, a region of the acetabulum, seen during arthro-
decrease in femoral neck offset, or an increase in scopic examination of the hip,17 most likely
relative circumferential over coverage of the represent femoroacetabular impingement. Al-
femoral head. All the latter conditions affecting though some of these patients may have a history
the acetabulum with a relatively normal proximal and clinical examination suggestive of traumatic
femur lead to pincer abutment of the rim against etiology and confirmation of labral tear, it is
the femoral neck and lesions limited to the rim the underlying femoroacetabular impingement,
area with deep chondral lesions being rarely however subtle, that leads to a labral lesion as
encountered. Pincer impingement is more com- part of a more extensive injury. This premise is
mon in middle-aged women with morphologic supported by the observation that the majority of
abnormalities of the acetabulum. This is in labral tears, seen during hip arthroscopy, also are
contrast to cam impingement, which is more associated with chondral injury.17 McCarthy et al,17
common in young males with morphologic ab- reporting more than 400 hip arthroscopies, noted
normalities involving the femoral head. A pre- a highly significant association between the
vious study from our institution, using an MRI- presence of labral lesions and degeneration of
based quantative anatomic study of the femoral the articular surface. The labral and articular le-
head and neck, confirmed that anatomic varia- sions almost always were located in the same
tions in the proximal femur were responsible for region of the acetabulum in their series and the
the cam femoroacetabular impingement.12 A relative risk of significant chondral lesion ap-
significant reduction in the mean femoral ante- proximately doubled in the presence of labral
lesions.17 Approximately 2/3 of their patients with of the adult hip: A technique with full access to
femoral head and acetabulum without the risk of
fraying or a tear of the labrum had evidence of avascular necrosis. J Bone Joint Surg 83B:1119–
chondral damage. It is plausible that some chon- 1124, 2001.
dral lesions may go undetected during hip 8. Gautier E, Ganz K, Krugel N, et al: Anatomy of the
medial femoral circumflex artery and its surgi-

arthroscopy that in turn accounts for the higher cal implications. J Bone Joint Surg 82B:679–683,
than expected incidence of isolated labral tears.
2000.
Through extensive clinical observations with 9. Gekeler J: Coxarthrosis with a deep acetabulum. Z
Orthop Ihre Grenzgeb 116:454–459, 1978.
more than 600 surgical dislocations of the hip, 10. Goodman DA, Feighan JE, Smith AD, et al: Sub-
we have observed that femoroacetabular impin- clinical slipped capital femoral epiphysis: Relation-
gent results in lesions of the joint and acts as a ship to osteoarthritis of the hip. J Bone Joint Surg
79A:1489–1497, 1997.
precursor for early degenerative disease of the 11. Harris WH: Etiology of osteoarthritis of the hip. Clin
hip in patients with idiopathic arthritis. Previous Orthop 213:20–33, 1986.
and ongoing studies have helped us gain insight 12. Ito K, Minka II MA, Leunig M, et al: Femoro-
acetabular impingement and the cam-effect: A MRI-
into the pathomechanism of conditions resulting based quantitative study of the femoral head-neck
in femoroacetabular impingement and paved offset. J Bone Joint Surg 83B:171–176, 2001.
the road for additional investigations to unravel 13. Klaue K, Durnin CW, Ganz R: The acetabular rim
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CLINICAL ORTHOPAEDICS AND RELATED RESEARCH

Number 417, pp. 112–120

A Cause for Osteoarthritis of the Hip

Reinhold Ganz, MD*; Javad Parvizi, MD**; Martin Beck, MD*;

A multitude of factors including biochemical, ge- Osteoarthritis is a disorder of diverse etiologies,

An orthograde AP radiograph taken with the

quality images, to observe the labrum and the

low offset of the neck, herniation pit, or os-

ment. Magnetic resonance arthrograms are very

Femoroacetabular impingement is a condition of

Fig 2A–C. (A) Femoroacetabular impingement is

Fig 3A–C. The (A) AP and (B) lateral radio-

medial femoral circumflex artery and its surgi-

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