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PubMed2006

[Hip arthroscopy for femoroacetabular impingement].

Femoroacetabular impingement (FAI) is likely one of the main causes for osteoarthritis in young adults. Surgical treatment has until now been performed via open dislocation of the hip joint. With respect to its invasive nature and long rehabilitation, arthroscopic techniques have become established in recent years. The following article presents the latest developments in hip arthroscopy for FAI with a detailed description of technical aspects, pitfalls, and limitations. Hip arthroscopy is performed in the standard fashion with and without traction for arthroscopy of the central and peripheral compartments. Under traction, the anterosuperior cartilage and adjacent base of the acetabular labrum have to be inspected for frequent lesions such as cartilage flap tears and delaminations of the cartilage from the subchondral bone. An ossified labrum can be trimmed back with a burr. Currently, techniques are being developed for temporary detachment of the labrum, trimming of the acetabular rim, and refixation of the labrum with suture anchors. Without traction, femoroacetabular impingement has to be confirmed arthroscopically under flexion, internal rotation, and adduction of the hip. With respect to the frequent loss of internal rotation, the zona orbicularis and the iliofemoral ligament are released and removed if needed. The anterolateral bump of the head-neck junction is trimmed back for restoration of a more physiological head-neck offset. Postoperatively, continuous passive motion is important to prevent adhesions between the bleeding bone of the head-neck junction and the articular capsule. Weight bearing as tolerated is allowed if no treatment of cartilage defects or refixation of the acetabular labrum was performed. The early results after hip arthroscopy for FAI are very promising. Arthroscopic techniques will upstage open exposures of the hip joint for the treatment of FAI.

Arthroscopy↗

PubMed2005

Three-dimensional computed tomography of the hip in the assessment of femoroacetabular impingement.

Femoroacetabular impingement secondary to the cam effect is thought to be associated with an insufficient anterior concavity in the sagittal/axial plane of the femoral head-neck junction. Using three-dimensional computed tomography the anterior and posterior concavity of the femoral head-neck junction was assessed in 36 painful non-dysplastic hips (30 patients). The mean age of the symptomatic hips was 40.7 with 13 females and 17 males. Eighteen out of the 36 hips had a pistol grip deformity. Magnetic resonance gadolinium arthrography was performed to assess for labral and cartilage lesions. Alpha and beta angles measuring the anterior and posterior femoral head-neck junction concavities were also determined in 20 asymptomatic hips (12 patients; mean age 37, 5 females and 7 males) using three-dimensional computed tomography. The mean alpha angle for the symptomatic and the control group were: 66.4 versus 43.8 (p=0.001), and for the beta angle 40.2 versus 43.8 (p=0.011), respectively. All but one of the symptomatic hips had a labral tear with 61% of these hips having associated cartilage damage. Three-dimensional computed tomography represents an accurate tool to quantify the femoral head-neck concavity providing a non-invasive assessment of hips at risk of femoroacetabular impingement.

Acetabulum↗

PubMed2005

Imaging findings of femoroacetabular impingement syndrome.

Femoroacetabular impingement syndrome (FAI) is a pathologic entity which can lead to chronic symptoms of pain, reduced range of motion in flexion and internal rotation, and has been shown to correlate with degenerative arthritis of the hip. History, physical examination, and supportive radiographic findings such as evidence of articular cartilage damage, acetabular labral tearing, and early-onset degenerative changes can help physicians diagnose this entity. Several pathologic changes of the femur and acetabulum are known to predispose patients to develop FAI and recognition of these findings can ultimately lead to therapeutic interventions. The two basic mechanisms of impingement-cam impingement and pincer impingement-are based on the type of anatomic anomaly contributing to the impingement process. These changes can be found on conventional radiography, MR imaging, and CT examinations. However, the radiographic findings of this entity are not widely discussed and recognized by physicians. In this paper, we will introduce these risk factors, the proposed supportive imaging criteria, and the ultimate interventions that can help alleviate patients' symptoms.

Acetabulum↗

PubMed2007

Range of motion in anterior femoroacetabular impingement.

The range of motion of normal hips and hips with femoroacetabular impingement relative to some specific anatomic reference landmarks is unknown. We therefore described: (1) the range of motion pattern relative to landmarks; (2) the location of the impingement zones in normal and impinging hips; and (3) the influence of surgical débridement on the range of motion. We used a previously developed and validated noninvasive 3-D CT-based method for kinematic hip analysis to compare the range of motion pattern, the location of impingement, and the effect of virtual surgical reconstruction in 28 hips with anterior femoroacetabular impingement and a control group of 33 normal hips. Hips with femoroacetabular impingement had decreased flexion, internal rotation, and abduction. Internal rotation decreased with increasing flexion and adduction. The calculated impingement zones were localized in the anterosuperior quadrant of the acetabulum and were similar in the two groups and in impingement subgroups. The average improvement of internal rotation was 5.4 degrees for pincer hips, 8.5 degrees for cam hips, and 15.7 degrees for mixed impingement. This method helps the surgeon quantify the severity of impingement and choose the appropriate treatment option; it provides a basis for future image-guided surgical reconstruction in femoroacetabular impingement with less invasive techniques.

Acetabulum↗

PubMed2006

Arthroscopy for the treatment of femoroacetabular impingement in the athlete.

Femoroacetabular impingement (FAI) has been recently recognized as a cause of hip pain, labral and chondral pathology, early osteoarthritis, and decreased athletic performance. Historically, treatment for FAI consisted of an open approach with surgical dislocation. It has been suggested that the operative trauma sustained during the open procedure may make it difficult for high-level athletes to return to play. As a result, an arthroscopic approach to treat FAI has been developed. The purpose of this article is to describe the arthroscopic technique for the treatment of cam and pincer-type hip impingement.

Acetabulum↗

PubMed2004

Femoroacetabular impingement as a factor in the development of nonunion of the femoral neck: a report of three cases.

OBJECTIVES: Description of an anatomic condition where a femoroacetabular impingement was identified as the cause for the development of nonunion of the femoral neck. DESIGN: Retrospective analysis. SETTING: University hospital. PATIENTS: Three patients, aged 27 to 74 years, in whom, after exclusion of other known factors, a femoroacetabular impingement was identified as the cause for the nonunion of a femoral neck fracture. INTERVENTION: Surgical correction of the femoroacetabular impingement. MAIN OUTCOME MEASUREMENT: Intraoperative verification of femoroacetabular impingement. Healing of the femoral neck non-union. RESULTS: In all 3 patients, femoroacetabular impingement was confirmed at surgery. After elimination of the cause for impingement, all nonunions went on to uneventful healing. CONCLUSIONS: A femoroacetabular impingement mechanism is proposed as a cause for nonunion of femoral neck fractures. Predisposing factors such as bulging at the fracture site or decreased femoral-neck offset should be addressed at the time of initial fracture treatment.

Adult↗

PubMedDate not supplied

Anterior femoroacetabular impingement after femoral neck fractures.

OBJECTIVES: To verify whether anterior femoroacetabular impingement can be a reason for hip pain and loss of motion in patients with a healed femoral neck fracture. DESIGN: Retrospective clinical, radiologic, and surgical evaluation. SETTING: Third referral hospital. PATIENTS: Nine patients who previously sustained a femoral neck fracture were treated between 1995 and 1999 for hip pain and loss of motion. All these mostly young patients (mean age 33.3 years) complained of groin pain. During the physical examination, acute pain could be elicited by passively forcing the femoral neck against the acetabular rim in flexion, adduction, and internal rotation, motions that were all limited. METHODS: Conventional radiographs and, if possible, arthrographic magnetic resonance imaging scans were followed by a surgical subluxation or dislocation of the femoral head to analyze the sequelae of anterior femoroacetabular impingement. Treatment was based on improvement of the anterior offset (the difference between the anterior contour of the head and the femoral neck) or intertrochanteric osteotomy to ameliorate clearance of the joint. RESULTS: Intraoperatively in eight patients (one not operated), impingement was found to result from insufficient reduction of the fracture, already visible on the conventional radiographs. Retrotorsion (mean 20 degrees) of the head caused anterior impingement in all patients, additional varus position (mean caput collum diaphysis angle 115 degrees) of the head caused anterolateral impingement in two patients. In all patients, anterior labral and adjacent acetabular cartilage lesions were found during surgical subluxation or dislocation of the femoral head, comparable to those seen on the magnetic resonance imaging scan. They proved to result from repetitive abutment and compression between the head-neck junction and the acetabulum. CONCLUSION: Femoroacetabular impingement can be a cause for hip pain and loss of motion in patients who previously sustained a femoral neck fracture. The condition causes degenerative anterior labral and adjacent acetabular cartilage lesions. Early treatment is essential to prevent further degeneration and osteoarthrosis of the joint. Prevention is predicated by initial precise anatomic reduction of such fractures in all planes.

Acetabulum↗

PubMed2006

Arthroscopic treatment of femoroacetabular impingement: a proposed technique with clinical experience.

Femoroacetabular impingement is a condition that primarily occurs in young and middle-aged adults. It is characterized by hip pain felt mostly in the groin. Radiographs often appear normal to the untrained observer; however, on careful analysis an anterior to lateral bump may be seen at the head-neck junction as an extension of the physeal line. An effective open technique using a safe surgical dislocation of the hip has been developed to alleviate femoroacetabular impingement. An arthroscopic equivalent of the open technique has been developed. Early results are favorable and may be comparable to those achieved with the open technique.

Acetabulum↗

PubMed2006

Femoroacetabular impingement: an overlooked cause of hip pain.

Femoroacetabular impingement is a cause of hip pain arising from abnormal contact between the proximal femur and the acetabulum during terminal hip motion. This is caused by a structural abnormality at the femoral head/neck junction or the acetabulum. The problem usually presents in young adults and can often go undiagnosed for years. Failure to identify and properly restore the biomechanics has been hypothesized to lead to the early onset of hip osteoarthritis; thus, early recognition is important. In this case study, we report on a 31-yr-old patient with many years of bilateral hip pain who underwent successful treatment of bilateral femoroacetabular impingement.

Acetabulum↗

PubMed2007

Influence of femoroacetabular impingement on results of hip arthroscopy in patients with early osteoarthritis.

To ascertain whether better results could be obtained using hip arthroscopy, we retrospectively reviewed the radiographic and clinical aspects of anterior femoroacetabular impingement in 43 patients diagnosed with early osteoarthritis with acetabular labral tears who previously had arthroscopic treatment. The average followup was 50 months. The patients were divided into two groups: patients who had no osteoarthritis seen on simple radiographs, but had degenerative changes of the labrum and cartilage seen on magnetic resonance arthrograms and arthroscopy, and patients who had osteoarthritic findings seen on simple radiographs. Both groups were examined retrospectively for signs of anterior femoroacetabular impingement at the acetabulum and proximal femur. Postoperative improvement was evaluated using the Japanese Orthopaedic Association pain score. Six of 21 patients in Group I and 12 of 22 of patients in Group II showed radiographic evidence of femoroacetabular impingement. The score improved from 0.76 preoperatively to 2.38 postoperatively in Group I and from 0.75 preoperatively to 1.90 postoperatively in Group II. Arthroscopic débridement produced improved results seen during short-term and midterm followups. However, in patients with femoroacetabular impingement the results were considered inadequate. We found that arthroscopic treatment of osteoarthritis of the hip fails if there is detectable femoroacetabular impingement.

Acetabulum↗

PubMed2004

Anterior femoroacetabular impingement: part II. Midterm results of surgical treatment.

Femoroacetabular impingement has been shown to cause labral and chondral lesions and leads to osteoarthrosis of the hip. With the elimination of the pathogenic cause we hope to prevent or delay additional degeneration of the hip. Fourteen men and five women with a mean age of 36 years (range, 21-52 years) were treated with a surgical dislocation and offset creation of the hip. The followup averaged 4.7 years (range, 4-5.2 years). Using the Merle d'Aubigné hip score, 13 hips were rated excellent to good, with the pain score improving from 2.9 points to 5.1 points at the latest followup. There was no avascular necrosis of the femoral head. Five of the 19 patients, two with Grade 2 osteoarthrosis, two with Grade 1 osteoarthrosis but severe acetabular cartilage damage, and one with untreated ossified labrum had subsequent total hip arthroplasty (THA). In the stable hips without subluxation of the head into the acetabular cartilage defect, no additional joint space narrowing occurred. Surgical dislocation with correction of femoroacetabular impingement yields good results in patients with early degenerative changes not exceeding Grade 1 osteoarthrosis. This procedure is not suitable for patients with advanced degenerative changes and extensive articular cartilage damage.

Acetabulum↗

PubMed2004

Histopathologic features of the acetabular labrum in femoroacetabular impingement.

This paper summarizes clinical and histopathologic findings derived from 25 patients who had surgery for symptomatic femoroacetabular impingement. We explored if observed pathologic features were consistent with hypothesized mechanisms of injury, if severity of osteoarthritis and labral degeneration were associated, and if labral refixation would present an alternative. Clinically, all patients presented with limited range of motion at the hip attributable to pain and a positive impingement test. Magnetic resonance arthrography and surgical observations showed degenerated or ruptured labra or both in the anterior and/or superior regions of the acetabular rim (24 of 25 specimens) which correlated with pain provocation, limited range of motion, and anatomic deformities. Histologically, labra were mostly hyperplastic with disorganized cystic matrices. No inflammation was observed. Spatial distribution of degenerated labral matrices was not different for the two femoroacetabular impingement mechanisms. Labral degeneration and severity of osteoarthritis observed on radiographs did not correlate. In patients having only joint debridement, the labral matrix at the tip, near its vascular supply, was normal. Femoroacetabular impingement is a gentle chronic irritation of the labra located at the site of rupture that elicits a degenerative reaction. In early stages of the disease, the labral tip is not involved, providing the possibility of labral refixation after resection of the degenerated portion.

Acetabulum↗

PubMed2005

Triad of MR arthrographic findings in patients with cam-type femoroacetabular impingement.

PURPOSE: To retrospectively analyze magnetic resonance (MR) arthrographic findings in patients with clinical cam-type femoroacetabular impingement. MATERIALS AND METHODS: This study was approved by the institutional review board, and informed consent was waived. Study was compliant with the Health Insurance Portability and Accountability Act. Forty-two MR arthrograms obtained in 40 patients with clinical femoroacetabular impingement were analyzed retrospectively by two radiologists. Quantitative analysis by using alpha angle measurement was performed to assess anterosuperior femoral head-neck morphology. Presence of labral tears, articular cartilage lesions, paralabral cysts, os acetabuli, and synovial herniation pits was recorded. Presence of the typical triad of anterosuperior labral tear, anterosuperior cartilage lesion, and abnormal alpha angle was recorded. Surgical comparison was available for 11 patients. RESULTS: At imaging, in 40 patients (22 male, 18 female) with a mean age of 36.5 years, 39 of 42 hips (93%) had an abnormal alpha angle, with a mean angle of 69.7 degrees ; 40 of 42 (95%) had an anterosuperior cartilage abnormality; and 42 of 42 (100%) had an anterosuperior labral tear. Thirty-seven of 42 hips (88%) had the triad. Six had paralabral cysts, 17 had an os acetabuli, and two had synovial herniation pits. Surgical comparison for 11 hips led to confirmation of all labral and cartilage abnormalities seen at imaging. CONCLUSION: MR arthrography demonstrated a triad of abnormal head-neck morphology, anterosuperior cartilage abnormality, and anterosuperior labral abnormality in 37 of 42 patients with cam-type femoroacetabular impingement.

Acetabulum↗

PubMed2004

Anterior femoroacetabular impingement: part I. Techniques of joint preserving surgery.

The exact pathomechanism responsible for osteoarthritis (OA) of the nondysplastic hip has remained unknown for many years. There is, however, emerging clinical evidence implicating femoroacetabular impingement as an etiologic factor for having early OA of the hip develop. Femoroacetabular impingement is an abutment conflict occurring between the proximal femur and the acetabular rim arising from morphologic abnormalities affecting the acetabulum or the proximal femur, or both. The repetitive mechanical conflict occurring during motion, particularly flexion and internal rotation, can lead to lesions of acetabular labrum and, even more serious, the adjacent acetabular cartilage. Surgical treatment of femoroacetabular impingement focuses on improving the clearance for hip motion and alleviation of femoral abutment against the acetabular rim. We will describe the rationale for the treatment of this condition, and discuss the technique of joint-preserving surgery.

Acetabulum↗

PubMed2006

MRI findings of femoroacetabular impingement.

OBJECTIVE: The purpose of our study was to evaluate MRI in the identification of labral and articular cartilage lesions in patients with a clinical suspicion of femoroacetabular impingement. MATERIALS AND METHODS: Preoperative MRI was performed in 46 consecutive patients (26 men, 20 women; age range, 21-45 years; mean age, 32.3 years) for whom femoroacetabular impingement was clinically suspected. Two musculoskeletal radiologists independently assessed the MR images for the presence and anatomic site of labral disorders, labral-chondral transitional zone disorders, femoral cartilage lesions, and acetabular cartilage lesions. Surgical correlation was obtained in all cases by two surgeons who were experienced in hip arthroscopy. RESULTS: Seven patients showed labral tears on MRI that were confirmed surgically in all cases. Thirty-seven patients (97%) of the 38 surgically confirmed cases had lesions of the labral-chondral transitional zone on MRI. The sites of labral-chondral transitional zone abnormalities at arthroscopy were 50% anterosuperior, 36% anterosuperior and superolateral, 11% superolateral, and 3% superolateral and posterosuperior. The site was identified correctly in 92% (reviewer 1) and 95% (reviewer 2) of cases on MRI. Separate acetabular cartilage abnormality was surgically identified in 39% of cases, and femoral cartilage lesions were found in 20%. The acetabular chondral lesions were correctly identified in 89-94% of cases. CONCLUSION: MRI provides a useful assessment of patients in whom a femoroacetabular impingement is clinically suspected. A high-resolution, nonarthrographic technique can provide preoperative information regarding the presence and anatomic site of labral and cartilage abnormalities.

Acetabulum↗

PubMed2004

Femoroacetabular impingement caused by a femoral osseous head-neck bump deformity: clinical, radiological, and experimental results.

Femoroacetabular impingement is often associated with reduced femoral anteversion or an osseous bump deformity on the femoral head-neck junction. We report prospectively on 17 patients showing an osseous bump at the anterolateral head-neck junction on radiography (22 hips) and typical signs of femoroacetabular impingement on clinical examination. Following three plans of treatment, nine patients (10 hips) underwent nonoperative treatment, and eight patients (12 hips) had surgery. In eight hips with labral defects but minor cartilage damage, the bump was surgically removed via trochanter flip osteotomy. Two hips were treated surgically through an anterior surgical approach without hip dislocation. Four hips with severe signs of osteoarthritis and significantly reduced range of motion underwent total replacement. To elucidate a local osteogenic differential potential, tissue specimens of the perilesional capsule were investigated immunohistochemically. Various antigens and protein synthesis products served to identify osteoblastic and progenitor cells. There was a significant improvement in internal rotation and pain relief in patients who underwent surgical resection of the osseous bump. No avascular osteonecrosis or other significant severe side effects were observed during follow-up. In contrast, no nonoperatively treated patients improved. Furthermore, immunohistochemical studies showed perilesional recruitment of osteoprogenitor cells.

Acetabulum↗

PubMed2006

[Femoroacetabular impingement: trigger for the development of coxarthrosis].

Femoroacetabular impingement (FAI) is frequent; the estimated prevalence ranges between 10 and 15%. Our 10-years experience strongly suggests that FAI leads to osteoarthritis. Isolated acetabular or femoral abnormalities are rare, even though in women acetabular and in men femoral abnormalities predominate. Normal radiographs do not exclude the presence of FAI. Symptoms are related to the degree of deformity and occur earlier in the presence of activities requiring high levels of motion. The majority of patients with FAI are under the age of 40 years. In contrast to impingement in total hip replacement, the natural hip is under much higher constraint, not allowing to escape from impingement-induced shear forces by subluxation or complete dislocation. FAI-induced shear forces due to an aspherical femoral head/neck (cam type) are therefore high, causing outside-in damage with cleavage lesions of the acetabular cartilage by forced flexion and internal rotation. The cartilage of the femoral head remains initially intact, which cannot be explained by the classic concept of osteoarthritis. After the femoral head has migrated into the acetabular cartilage defect, vertical forces contribute to the further course of osteoarthritis. Tears between the labrum and cartilage, as seen by MRI, are not avulsions of the labrum from the cartilage but rather outside-in avulsions of the cartilage from the labrum. In acetabular overcoverage (pincer type) the labrum is the first structure to fail and acetabular cartilage damage develops thereafter. The treatment of FAI in patients under the age of 40 years is aimed at joint preservation. The clinical result is worse in the presence of significant cartilage damage. Therefore, early appreciation of FAI and timely therapeutic intervention as well as professional and athletic adjustment are important if osteoarthritis is to be prevented.

Hip Joint↗

PubMed2003

Femoroacetabular impingement: a cause for osteoarthritis of the hip.

A multitude of factors including biochemical, genetic, and acquired abnormalities may contribute to osteoarthritis of the hip. Although the pathomechanism of degenerative process affecting the dysplastic hip is well understood, the exact pathogenesis for idiopathic osteoarthritis has not been established. Based on clinical experience, with more than 600 surgical dislocations of the hip, allowing in situ inspection of the damage pattern and the dynamic proof of its origin, we propose femoroacetabular impingement as a mechanism for the development of early osteoarthritis for most nondysplastic hips. The concept focuses more on motion than on axial loading of the hip. Distinct clinical, radiographic, and intraoperative parameters can be used to confirm the diagnosis of this entity with timely delivery of treatment. Surgical treatment of femoroacetabular impingement focuses on improving the clearance for hip motion and alleviation of femoral abutment against the acetabular rim. It is proposed that early surgical intervention for treatment of femoroacetabular impingement, besides providing relief of symptoms, may decelerate the progression of the degenerative process for this group of young patients.

Acetabulum↗