is it real? femuro-acetabularimpingement fai · hip arthroscopyfor oa? ref n anm fu failurerate...

1

Femuro-Acetabular ImpingementFAI

Dr Anders Valentin

• YES, since a long time ago…

– 1920 - Sir Robert Jones

– 1936 - Smith Petersen

– 1949 - Heyman

• Pistolgrip

– 1975 - Stulberg

Is It Real?

Is This FAI?

How To Define FAI?

• Symptomatic conflict between bone och ”soft tissues”– Pain– Reduced ROM– Reduced function/activity level

Background to FAI/Risk Factors

• Morphology – Risk Factor

• Activity – Risk Factor

• Pathology

– Labrum

– Articular Cartilage

– Synovia

– Psoas

Symptom/FAI

Pathologyand/orSymptoms

2

Potential Morphological Contributors to Pathology

Pincer(Pelvis)CAM(Femur)

CAM Pincer

Labrum

Safran_JAAOS2010_vol 18_6

Labral Tears

• FAI

• Degenerative (age)

• Dysplasia (stress)

• (Trauma)

3

What Is Causing The Morpholgy?

• Some hereditary factors

– Anatomy/configuration

• Heavy loading/training at young age

– Remodelling of growth plates

• Fysiolysis (SCFE)

– Slipped Capital Femoral Epiphysis

– Manifest/”subclinical”

Heredity

• Evolution ref bilder

• Bilder olika bäcken

• Ex dysplasi, profunda, retroversion

• ref

Genetic Influences Are Important in the

Aetiology of Primary FAI

A TWIN STUDY

2010

T. C. B. Pollard; R. N. Villar; M. R. Norton; E. D. Fern; M. R. Williams; D. W. Murray; A. J. Carr

Remodellering av tillväxtzonen Slipped Capital Femoral Epiphysis

4

What To Be Aware Of?

• Relatively young patients (20-40)

• Groin pain

– Position

– Activity

• Reduced ROM

– Rotation/flexion

• CAM – male > female

• Pincer – female > male

How To Make The Diagnosis?

1. History

2. Clinical exam

3. Imaging

X-ray/MRI/MRA/CT/3D-CT

What Are The Typical Symptoms?

• Pain

– Position (Flexion/internal rotation)

– Activity

• Mechanical symptoms

– Catching/locking

• Reduced ROM/stiffness

Clincial Findings

• Restricted ROM, flexion and internal rotation

• Drehmann’s sign = unavoidable passive external rotation in deep hip flexion

• FADIR test = Impingement test

• FABER test

Impingement Test Drehman’s Sign Posterior Impingement

Pos Impingement Test

5

FABER Test

Flexion ABduction External Rotation

Imaging

• X-Ray• CT Scan

– ”Normal” CT– 3D reconstruction– 3D Dynamic Simulation

• MR– MRI – MR-Arthrogram– dGEMRIC (Delayed Gadolinium Enhanced MRI Cartilage)

• 3D• Iv/ia

• (Ultrasound)

Normal AP Hip

Normal AP HipAnterior & Posterior walls of

Acetabulum

6

Ischial Spine Sign

Linear Indentation SignPincer

Femoral SideHead-Neck Offset (HNO)

MR Axial Oblique CAM Lesion MRI Alfa angle (Nötzli)

7

What Treatment Can We Offer?

• Non-operative?– Reduced activity level!– Physiotherapy?

• Pelvic tilt

• Surgery– Arthroscopic surgery

• Since > 10 years• Nn publications

– Open surgery• Professor Gantz – Hip preservation surgery, Bern, 1980:s• Nn publications

Treatment Goals?

• Reduce/eliminate symptoms

– Pain

– Mechanical symptoms

• Improve function

– Daily life

– Sports

• Better future

– Elimininate morphological risk factors

– Reduce risk for OA???

Surgical Treatment

• CAM excision

• Rim Trimming

• Labrum

– Refixation

– Resection/stabilization

– Reconstruction

• Cartilage

– Debridement, microfracture

Surgery

8

”Before”

”After”

CAM Scientific Support?

• Numerous publications last 10 years

• Increasing consistently

• Limited size and F.U.

• Various evaluation tools

• More publications about arthroscopic FAI surgery than open!

Examples• Malviya et al. (2012) Athletes and non-athletes who underwent arthroscopy for

FAI had positive results.

• Byrd and Jones (2011) 2-year follow-up arthroscopy for FAI. N=100 consecutive cases Mean age 34 years (13-76). The authors concluded arthroscopic management of FAI has favorable outcomes.

• Schilders et al. (2011) A comparative study of refixation and resection of arthroscopic treatment of labral tears in FAI. N=151 patients with a minimum 2-year follow-up . Patients without advanced degenerative changes in the hip can

achieve significant improvement in symptoms after arthroscopic treatment of

FAI.

• Philippon et al. (2009) N=112 Arthroscopy for FAI. Mean 2,3-year follow-up Arthroscopy accompanied by suitable rehab give good short-term outcomes and

high patient satisfaction.

• Gedouin et al. (2010) found the results of their study confirmed the efficacy and

low associated morbidity of arthroscopy in the management of FAI. N=111. Mean 10 months follow-up, 77% of patients were satisfied or very satisfied.

Examples

9

• Brunner et al. (2009) found that arthroscopic osteoplasty significantly improved

the rate and level of popular sports activities in patients with FAI. N=53. Mean follow up 2.3 years. 45 of the 53 patients had been active in sports before the surgery and 31 of the 45 had returned to their full accustomed level of activity at the final follow-up.

• Byrd and Jones (2009). Prospective study. N=207 hips. CAM impingement. Mean follow-up 16 months, average age 33. 163 hips underwent correction of cam impingement alone, and 44 hips underwent concomitant correction of pincer impingement. Average increase of HHS was 20 points. The complication rate for the group was 1.5%. Byrd and Jones found the short-term outcomes of the

treatment to be comparable to published reports for open methods with the advantage of a less invasive approach.

Examples

• A 2008 systematic review by Bedi et al. found clinical literature did NOT show open techniques to have superior outcomes to arthroscopic techniques for young, active patients with FAI.

• Larson and Giveans (2008) found arthroscopic management of patients (N=96) with FAI resulted in significant improvement in a number of outcome measures with good to excellent results observed in 75% of hips at a minimum 1 year

follow up. Significant improvements were seen in HHS, VAS for pain, and positive impingement tests. 3 hips went on to total hip arthroplasty.

• Guanche and Bare (2006) stated arthroscopic treatment of FAI syndrome caused by an abnormal head-neck offset improves symptoms, restores hip morphology, and may arrest the progression toward degenerative join disease in some patients. They noted early results are promising. Wettstein and Dienst (2006) agreed with these observations and also stated the early results after hip arthroscopy for treatment of FAI syndrome are very promising.

Examples

• In a 2007 study by Katz and Gomoll, they noted hip arthroscopy is permitting minimally invasive approaches to the management of FAI. While they observed complications

occur very rarely, they did state that VIRTUALLY ALL LITERATURE ON ARTHROSCOPY

OUTCOMES COMES FROM SMALL UNCONTROLLED STUDIES WHICH MAY

COMPROMISE THE STRENGTH OF RECOMMENDATIONS REGARDING THE ROLE OF

THESE ARTHROSCOPIC SURGICAL TECHNIQUES IN CLINICAL PRACTICE.

• 13 patients (14 hips) with FAI secondary to pediatric hip disease were treated with hip arthroscopy (Ilizaliturri Jr. et al. 2007). Using the WOMAC index, researchers compared pre and post-operative mean WOMAC scores. Pre-op, the mean WOMAC score was 77.7 and post-op follow up was 87.7. Researchers noted the WOMAC index had not been designed to evaluate hip arthroscopy. Other limitations of the study included small patient population, short-term follow up and lack of a comparison group.

• Philippon et al. (2007) retrospectively reported the outcomes of 45 professional athletes treated with hip arthroscopy for FAI. Follow up ranged from six months to five years with a mean of 1.6 years. Of the 45 athletes, 35 were professionally active at an average of 1.6 years following the procedure. This study was also limited by a small patient population and short-term follow up.

Examples• 156 patients (158 hips) were treated by hip arthroscopy for FAI in a preliminary

study reported on by Sampson (2005). Maximum follow up was 22 months. Following the procedure, pain was reduced by 50% at three months, 75% at five months and 95% at the end of the first year. Sampson’s study was limited by the lack of comparison group and short term follow up.

Examples

Is There Any EVIDENCE?

2010

Is There Strong EVIDENCE?

10

Evidence

• Search: 1990 - 2010: Scopus, Medline, CINAHL, Pubmed, Ausport, SportsDiscus, PEDro, the Cochrane Library, PsychINFO and Google Scholar.

• 4610 publications

• 29 considered OK

2012 What Is Negative For The Prognosis at Surgery?

• Long symptom duration (age/degenerative changes…)

• Reduced joint space

• Visible cartilage damage at MRÍ

Connection FAI/OA?

• Is morphology a risk factor?• Is symptomatic FAI a risk factor?• Hur big is the risk?

– Natural history– Post surgery

• Unchanged?• Reduced?• Increased?

Morphological risk factors for OA

Will ”Post-slip Deformity” Cause OA?

Elmslie, R. C.: Remarks on aetiological factors in osteoarthritis of the hip-joint.British Med. J. 1933; 1:1-3.

Law, W.: Osteoarthritis of the Hip. London,Butterworth, 1952.

1933• Mechanisms are clear

• Scientific publications

• Morphologi/FAI is a risk factor!

– All CAM/Pincers don’t seem to lead to OA

Connection FAI/OA?

11

JBJA Journal of Bone and Joint Surgery - American 1996 – 1998; October 1997, Volume 79-A, Number 10

1489 Subclinical Slipped Capital Femoral Epiphysis. Relationship to Osteoarthrosis of the Hip;GOODMAN et al.

Epidemiology”Post Slip Morphology”

2665 complete human disarticulatedskeletons from the Hamann-Todd osteologicalcollection at the Cleveland Museum of Natural

History that had been gathered from the unclaimeddead at the Cleveland city morgue between 1893 and

1938.





Total > 56YO

SCFE 38% 68%

Kontrollgrupp 26% 46%

We concluded that post-slipdeformity was a major risk factor in the

developmentof severe osteoarthrosis





12

• Pincer

• Labrum tear

• Posterior Cartilage

• CAM

• Labrum tear

• Anterior Cartilage

Ant

Ant

Figure 5

MR arthrography and ia-dGEMRIC revealing severe T1Gd changes with decreased T1Gdvalues peripheraly and centrally in the superior aspect of the hip.Delayed gadolinium-enhanced magnetic resonance imaging of hip joint cartilage: pearls and pitfallsOrthop Rev (Pavia). 2011 September 6;3(2):e11.

Hip Arthroscopy for OA?

Ref N Anm FU Failure rate

Horisberger M, Brunner A, Herzog RF.Arthroscopic treatment of femoral acetabularimpingement in patients with preoperative generalized degenerative changes.Arthroscopy. 2010;26:623–629.

20 NAHS >3 år 60%

Margheritini F, Villar RN.

The efficacy of arthroscopy in thetreatment of hip osteoarthritis] [in English, Italian].Chir Organi Nov. 1999;84:257–261.

133 HHS 18 m 36%

Walton NP, Jahromi I, Lewis PL.

Chondral degeneration and therapeutic hip arthroscopy.Int Orthop. 2004;28:354–356.

39 4 m 72%

Christopher M. Larson MD, M. Russell Giveans

PhD, Mehul Taylor MD

Does Arthroscopic FAI Correction Improve Function with Radiographic Arthritis?Clin Orthop Relat Res 2011 469:1667–1676

227(169+58)

HHS,SF12, VAS

>12 m

Hip Arthroscopy for FAI if OA?

• > 2 mm joint space width

• Better chance if short history/low age

• Temporary improvement/”an asymptomaticwindow before the THR”

• If you find cartilage damage at surgery

– Less successful…

13

Future?

• Increasing number of surgeries (2013 - 70000 in USA)

• Nn publications/year rapidly increasing

• Research/technical development

– Reasons/underlying mechanisms

– Profylaxis/screening/selection/warning signs

– Ex. Mayo Clinic

• Screening of morphologi (compare with scoliosis screening)

• Randomised study open/artrhoscopic surgery

• Diagnostics

– MR - dGEMRIC

– Computerized 3D dynamic analyses

• Operative technique

– Preop planning/Templates

– Technical guiding at surgery

• Rehabilitation

– Non operative treatment?

– Improved accellerated postoperative rehab

Future?

is it real? femuro-acetabularimpingement fai · hip arthroscopyfor oa? ref n anm fu failurerate...

Documents