Hip Update 2017 – Femoroacetabular Impingement (FAI) - PowerPoint Presentation

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Hip Update 2017 – Femoroacetabular Impingement (FAI)

May 26, 2017Daniel Abourbih, PGY4Sports and Exercise Medicine Fellow – McMaster UniversityEmergency Medicine Resident – University of TorontoSlide2

Presentation Outline

History Hip ImpingementWarwick AgreementConsensus QuestionsDiagnostic terminologyClinical featuresImaging strategiesTreatment optionsPrevention

Management of asymptomatic Slide3

Overview of Hip Impingement

Concept first presented in 1936 – Sporadic mentionGanz et. Al 2001-2003Proposed link between FAI and OANew surgical approach for improvement of Fem/Acetabular clearance365% increase in Hip Arthroscopy over a 6 year period (1)

Multiple ControversiesExact definitionPrevention and Treatment StrategiesRisk factor for OA developmentHealth care economics concerns:New diagnosisAmbiguity of diagnostic criteria

Costs and benefits of treatment uncertainSlide4

Warwick Agreement

PURPOSE: International and Multidisciplinary agreement on the diagnosis and treatment of FAIOpen Meeting – Sports Hip Conference (June 27-28, 2016)Proposed questions presented and evidence providedConsensus Panel of Practitioners involved in FAI Management (June 29, 2016)

Sports and Exercise Medicine PhysiciansPhysiotherapistsOrthopedic SurgeonsRadiologists22 Clinicians/Academics, 1 patient9 countries5 specialties representedSlide5

Consensus Questions

What is FAI Syndrome?How should FAI Syndrome be diagnosed?Appropriate Imaging Modalities?What is the appropriate treatment for FAI Syndrome?What is the prognosis for FAI Syndrome?How should asymptomatic individuals with CAM or Pincer Morphology be managed?Slide6

Agreement Meeting

June 29, 2016Panel vote on each proposalLikert Scale 0-100 – Complete Disagreement5 – Neither Agreement or Disagreement10 – Complete AgreementDiscussions continued until:

Mean score >7.5Chairman deemed no further compromise possibleSlide7

What is FAI Syndrome?

A motion-related clinical disorder of the hip with a triad of symptoms, clinical signs and imaging findingsSymptomatic premature contact between the proximal femur and the acetabulumLevel of agreement: mean score 9.8 (95% CI 9.6 to 10)KEY Feature of Definition = Must be symptomatic

Hip Radiographic morphology without symptoms NOT includedPrior definitions included (2):Abnormal morphology of Femoral Head and AcetabulumAbnormal contact between above structuresSupraphysiological motion causing abnormal contactRepetitive contact causing injurySlide8

Suggested TerminologySlide9

CAM Morphology

Bony overgrowth at Femoral Head/Neck JunctionResults in Non-spherical CAM shaped morphology

CAM impingement – Femoro-Acetabular contact in Flexion/Internal RotationAssociated with Antero-Superior Labral and Chondral DamageDescribed by Alpha AngleQuantifies the extent to which the femoral head deviates from sphericalNormal <55-60 deg

Other: Pistol Grip Deformity

Found in 15-25% of PopulationSlide10

Pincer Morphology

Pathological contact between the acetabular labrum and rim and the femoral head-neck junction – Essentially Acetabular

Overcoverage

Labral Injury, Less Chondral Injury

May result in Labral Ossification worsening

overcoverage

Associated with:

Acetabular Retroversion

Coxa

Profunda

Protrusio

AcetabuliSlide11
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How should FAI be diagnosed?

Symptoms, clinical signs, and imaging findings must be presentLevel of agreement 9.8/10 (95% CI 9.6-10)Primary Symptoms of FAIMotion-related Hip/Buttock pain – “C-sign”Pain can also be felt in back, thigh, and kneeMechanical symptoms – Clicking, catching, locking, stiffness, giving way

Presenting Symptoms VarySome experience with Vigorous Activity – Ex. FootballOnset with supraphysiologic motion – Ex. Dance, GymnasticsPresent at rest – Ex. Prolonged sittingSlide13

Clinical Signs required?

Diagnosis does not depend on single clinical signSignificant heterogeneity in performance and interpretation of PE maneuversStudied in populations with high Pre-test ProbabilityHip Impingement test generally reproduce patient’s symptomatology (3)FADIR – Sensitive but not specific (High False Positive Rate)

Sensitivty 94-99%Specificity 9-23%Typically restricted internal rotationSuggested Physical Exam should include:Gait, single leg control

Muscle tenderness around hip

Hip ROM – Internal and External rotation

Special tests – FABER, FADIR, Log RollSlide14

Role of Image-guided injection in Diagnosis?

Multiple potential soft-tissue confounders to diagnosisLumbosacral spine, Iliopsoas/Adductor Strains, GT Bursae, Gluteal Ensethopathy, Piriformis SyndromeAuthors do advocate the use to Image-guided IA local anesthetic injections – Fluro or U/S guided (4)

Has been shown to differentiate intra-articular from Extra-articular pathologiesSlide15

Imaging for FAI Syndrome?

AP Pelvis and Lateral Femoral Neck ViewAP pelvis – Centered on Pubic Symphysis, Limit rotation and pelvic tiltLateral view – Cross-table lateral, Dunn and frog lateralCAM – Flattening or convexity at the Femoral Head/Neck junction

Pincer – Global or focal femoral head over coverage by the acetabulumSlide16

Advanced Imaging?

Limitations of Plain RadiographsLow sensitivity for morphology detectionEx. CAM alpha angles – Poor sensitivity discriminating Symptomatic and Assymptomatic (6)

Recommend Cross-sectional ImagingFurther assessment of morphology, 3D reconstructionMRI Arthrogram suggested - Associated cartilage or labral injuryAssessment of other possible Hip/Groin soft tissue causes of painAlways correlate with clinical symptomsAssymptomatic Labral Tears

Assymptomatic

CAM/Pincer MorphologiesSlide17

Treatment for FAI Syndrome?

Can be treated by Conservative care, Rehabilitation, or SurgeryConservative treatment – Education, Watchful waiting, or lifestyle and activity modificationRehabilitation – Improve hip stability, neuromuscular control, strength, ROM, and movement patterns

Surgery – Open or arthroscopic, repair soft-tissue damage and correct FAI morphologyLevel of agreement: mean score 9.5 (95% CI 9.0 to 10)Emphasized Shared decision options – Practically, a trial of conservative and rehabilitation prior to surgical optionsSlide18

Rehabilitation Protocol?

Heterogenous Interventions suggestedTaping/PositioningGluteal/Abdominal strengtheningHip flexor strengtheningCore strengtheningNo High Quality RCT data availableGRADE Quality of Evidence: Low to Very LowSlide19

Hip Arthroscopy

Primary Surgical corrective techniqueTreatment of Labral and Chondral injuries in the central compartment by tractionAllows Femoral/Acetabular bony correctionInadequate/Inappropriate bone correction – Most common cause of treatment failureOvercorrection – Risk of Femoral Neck #, Loss of Hip fluid seal

Overall complication rates low (<4%)Lat Fem Cutaneous nervePudendal nerveIatrogenic labral/chondral damage Slide20

Open vs. Surgical Correction of CAM DeformitySlide21

Open Surgical Hip Dislocation?

May be more ideal treatment for severe/complex FAI DeformitiesCAM Lesions with Posterior ExtensionSevere Global Acetabular OvercoverageExtra-articular impingement

Relatively low rates of complicationTrochanteric Non-union 1.8%Longer recovery times documentedSlide22

Surgical Outcomes?

Casartelli NC, et al. Br J Sports Med 2015;49:819–824Systematic review of 1076 HipsEqual distribution of M:F, High level to Recreational Athletes73% Arthroscopic, 21% Open ApproachFemoral Osteoplasty 90%, Acetabular Rim Trimming 51%

Labral Tear Treatment38% repaired35% debrided6% Partialy resectedAcetabular and Femoral Cartilage treatmentRehabilitation ProtocolsLevel IV – Low level Evidence (Case Series)

Rate of Return to Sport = 87% (56-100%)

Rate of Return to SAME level = 82% (55-100)Slide23

Prognosis for FAI?

Cam morphology is associated with hip osteoarthritis.OR range from 2.2-20OA risk may depend on degreeModerate Alpha >60 deg – OR 2.5Severe Alpha > 83

deg – OR 9Pincer Morphology less closely relatedIt is currently unknown whether treatment for FAI syndrome prevents hip osteoarthritis. Level of agreement: mean score 9.6 (95% CI 9.3 to 9.8).Slide24

Asymptomatic CAM/Pincer Morphology

Environmental CausesSuggested 2nd to excessive Hip Loading89% Prevalence in Skeletal Mature Bball

50% in Symptomatic Soccer PlayersOnly 9% found in cohort of pre-pubescent males?Physeal Damage or Physiological Adaptation to StressShould we limit/alter the activity of Adolescents demonstrating CAM morphology?Slide25

Asymptomatic CAM/Pincer Morphology

Many patient with radiographic evidence WON’T develop OAPPV = 6-25%NPV = 98-99%Other Factors at playLevel of activityDegree of impingement

Obesity/Trauma/Classical OA risk factorsCurrent RecommendationsNo role for Preventative SurgeryPreventative Physio-Led rehabilitation suggestedSlide26

Summery of Recommendations

FAI Syndrome is clinical triad of symptoms, signs, and radiographic featuresXrays/Crossectional Imaging and Image-guided injections are a key component in diagnosisLifestyle modification, Physiotherapy, and other conservative measures form the backbone of basic treatment

Arthroscopic repair has supplanted open techniques for most repairsCAM morphology associated with OA but unable to predict which individuals are truly at riskSlide27

Future DirectionsSlide28

References

Montgomery SR, Ngo SS, Hobson T, et al. Trends and demographics in hip arthroscopy in the United States. Arthroscopy 2013;29:661–5Sankar WN, Nevitt M, Parvizi J, et al. Femoroacetabular

impingement: defining the condition and its role in the pathophysiology of osteoarthritis. J Am Acad Orthop Surg 2013;21(Suppl 1):S7–S15Kivlan BR, Martin RL, Sekiya JK. Response to diagnostic injection in patients with

femoroacetabular

impingement, labral tears, chondral lesions, and extra-articular pathology. Arthroscopy 2011;27:619–27

Reiman

MP, Goode AP, Cook CE, et al. Diagnostic accuracy of clinical tests for the diagnosis of hip

femoroacetabular

impingement/labral tear: a systematic review with meta-analysis. Br J Sports Med 2015;49:811.

Sutter R, Dietrich TJ,

Zingg

PO, et al. How useful is the alpha angle for discriminating between symptomatic patients with cam-type

femoroacetabular

impingement and asymptomatic volunteers? Radiology 2012;264:514–21.

Wall PD, Fernandez M, Griffin DR, et al. Nonoperative treatment for

femoroacetabular

impingement: a systematic review of the literature. PM R 2013;5:418–26.