update on femoroacetabular impingement (fai) · what are risk factors for revision after hip...
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Dr. S. GhijselingsDienst Orthopedie, UZ Leuven
13/2/2018
Update on femoroacetabular impingement (FAI)
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Casus
• Man - 31j
• Heuppijn bij voetballen
• Geen pijn bij wandelen
• Geen pijn ‘s nachts
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Anamnese
• In auto zitten pijnlijk
• Pijn in lies regio
• Adductor letsels in voorgeschiedenis
• Pijn bij hoesten / niezen?
• Pijn buikspieren?
Heup impingement
Femoroacetabulair impingement (FAI)
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What is FAI ?
FAI morphology FAI syndrome
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What is FAI ?
FAI morphology
Definitions
Etiology
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What is FAI ?
FAI morphology FAI syndrome
Symptoms
OA
Treatment
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Ganz, CORR
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CAM definition
Nötzli, JBJS Br 2002
Alpha angle
Axial MRI
Normal: 42°
Pathological: > 55°
Radial MRI
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How prevalent is a CAM morphology?
• Depends on definition (XR – CT – MRI & alpha-angle)
• More in athletes (Football, Icehockey, Basketball, American Football,…)
• More in males
• Ethnic differences
5% 75%
AthletesGeneral population
10 - 20%
Etiology ??
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Etiology of CAM
Dose response:
football 4 times /week on high level ?
Tak et al. BJSM 2015
After 12 y Before 12 y
CAM > 60° FLL 40% 64%
CAM > 78° FLL 12% 30%
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When do CAMs develop?
Agricola, AJSM, 2014
• 63 preprofessional football players
• 14y (12 – 19y)
• AP & frog leg X-rays
• Base line – 2y follow-up
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Concave Flat
Flat Bump
Open physis
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Concave = concave
Flat = flat
Bump = bump
Closed physis
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Agricola, AJSM, 2014
Cam deformities develop around age of 13 y
Increase in size during adolescence
Do not occur after physeal closure
Bone adaptation in response to athletic activities during growth
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Pincer definition
Much less clear
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Pincer definition
Much less clear
CEA > 39°Centre edge angle
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Pincer definition
• Focal retroversion
• Global retroversion
• Profunda
• Protrusio
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Pincer definition
• Focal retroversion
• Global retroversion
• Profunda
• Protrusio
Profunda Protrusio
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How prevalent is a PINCER morphology ?
4% 71%
General population
• More common in women
• Influence of sports?
10%
Etiology ?
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What is FAI ?
FAI morphology FAI syndrome
Symptoms
OA
Treatment
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FAI syndrome
Symptoms + clinical signs + diagnosticimaging
Symptomatic premature contact between proximal femur andacetabulum
Griffin, Br J Sports Med, 2016
The Warwick Agreement (2016)
Motion – related clinical disorder
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CAM impingement
- Shear force
- Delamination at chondrolabral
junction
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Pincer impingement
- Linear contact
- Labral crush
- Contre-coup lesion
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Symptoms
C – signTypical sign of intra-articular pathology
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FADIR + limited internal rotation
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X-rays
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Technische onderzoeken
(arthro) - MRI heup Bekken
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Does a CAM cause symptoms?
CAM > 50,5° RR 4,3 pain at 4,4yMRI, 1.30h
Only 15,9% hips with CAM developed hip pain. MOST DIDN’T
Khanna, AJSM, 2014
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Cause of OA ?
Impingementmorphology
FAI Articular damage OA
Variables • Activity• Genetic factors• BMI• Gender• Ageing• Muscle balance• ….
- Cam- Pincer- Combined- Extra-articular- Femoral version- Acetabular version
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Is a CAM a cause of OA?
Agricola, Ann Rheum Dis, 2013
CAM > 60° OR 3,6 end stage OA at 5y
> 83° OR 9,6
> 83° & IR <20° PPV 52% end stage OA
AP pelvic XR
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CAM & OA
Not all CAMs become symptomatic !
CAM is a risk factor for hip pain & OA
The bigger the CAM, the more symptoms & OA
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Pincer & OA
Conflicting evidence !
PINCER morphology FAI Articular damage /OA
Hosnijeh (Arthritis & Rheumatology, 2017)No increase risk of OA (CEA >40°) at 9,2y
Risk factor No effect Protective
Agricola (Osteoarthritis & Cartilage, 2013)CEA>40° AP + FP = OR 0,34 voor OA
Nicholls (Arthritis Rheum, 2011)No association pincer & THR at 19y
Gosvig (JBJS am, 2011) deep socket RR 2,4
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Can we fix it ?
Impingementmorphology
FAI Articular damage OA
Variables • Activity• Genetic factors• BMI• Gender• Ageing• Muscle balance• ….
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Conservative treatment
• Physiotherapy• Core stability training• Gluteus medius training• Stretching hamstrings + adductor• Pelvic tilt correction
• Intra-articular infiltration
• Avoid /stop painful activities
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Surgery
Open chirurgische luxatie Heuparthroscopie
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Geen degeneratieve veranderingenCave: vrouwen ouder dan 40 !
Indicatie voor heelkunde
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Behandeling
Chirurgische heupluxatie
Arthroscopisch
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Behandeling - open ingreep
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Heuparthroscopie
Anterolateral portal
Trochanter
Anterior portal Mid - Anterior portal
Supine on traction table
SIAS
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Heuparthroscopie
Anterolateral portal
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Heuparthroscopie
FH
Acetabulum
Anterior portal
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Heuparthroscopie
Capsulotomy• Interportal
• Limited
Anterior portal
Anterolateral portal
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Heuparthroscopie
CAM resectie
Perifeer compartiment
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Heuparthroscopie
Labrum herstel
Centraal compartiment
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Heuparthroscopie
Microfracture
Centraal compartiment
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Results
• 80% clinical improvement
• Low complication rate
• Long rehab: 3-6 months
• Risk factors
• Preop cartilage quality
• Under or over correction
• Age
• Labral repair > labral resection
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97 hips (FU 10-13 years)
• 11 THA• 8 progressive OA• 3 poor clinical outcome
Risk factors: age >40 y, BMI, CEA < 22° or > 32°
Open dislocation
80% of patients with surgical dislocation have good clinical resultwithout OA progression at 10 years
Steppacher, CORR, 2015
20% failure
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Arthroscopy
Haefeli, CORR, 2017
What are Risk Factors for Revision after Hip Arthroscopy for FAI at 7-years ?
52 hips (FU 5-11y, mean 7)
• 2 THA• 6 progressive OA• 6 poor clinical outcome
Risk factors: Pincer impingement, lateral CAM,residual FAI
15% failure
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Osteoarthritis and Cartilage,2016
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What evidence do we have?
6 RCT running+ Sham surgery
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Take home message
FAI = dynamisch conflict
CAM = risico op heuppijn en artrose
Niet alle CAM’s symptomatisch
Initiële behandeling = conservatief
Heelkunde geeft goed resultaat naar pijn
Effect van heelkunde op artrose?
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Kniepijn bij 10 – 16 jarige
11-jarig meisje met vage last in de lies of/ en de knie al enkele weken
25/1/2018
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Kniepijn bij 10 – 16 jarige
11-jarig meisje met vage last in de lies of/ en de knie al enkele weken
25/1/2018
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Kniepijn bij 10 – 16 jarige
11-jarig meisje met vage last in de lies of/ en de knie al enkele weken
R/ steunzolen
![Page 57: Update on femoroacetabular impingement (FAI) · What are Risk Factors for Revision after Hip Arthroscopy for FAI at 7-years ? 52 hips (FU 5-11y, mean 7) • 2 THA • 6 progressive](https://reader034.vdocuments.us/reader034/viewer/2022051814/603755eee76d09229941e1c8/html5/thumbnails/57.jpg)
Kniepijn bij 10 – 16 jarige
• Acute toename van de pijn
• Onmogelijkheid tot steuname
• Gefixeerde exorotatie
• Verkorting
4/2/2018
![Page 58: Update on femoroacetabular impingement (FAI) · What are Risk Factors for Revision after Hip Arthroscopy for FAI at 7-years ? 52 hips (FU 5-11y, mean 7) • 2 THA • 6 progressive](https://reader034.vdocuments.us/reader034/viewer/2022051814/603755eee76d09229941e1c8/html5/thumbnails/58.jpg)
Kniepijn bij 10 – 16 jarige
Epifysiolyse
![Page 59: Update on femoroacetabular impingement (FAI) · What are Risk Factors for Revision after Hip Arthroscopy for FAI at 7-years ? 52 hips (FU 5-11y, mean 7) • 2 THA • 6 progressive](https://reader034.vdocuments.us/reader034/viewer/2022051814/603755eee76d09229941e1c8/html5/thumbnails/59.jpg)
Kniepijn bij 10 – 16 jarige
![Page 60: Update on femoroacetabular impingement (FAI) · What are Risk Factors for Revision after Hip Arthroscopy for FAI at 7-years ? 52 hips (FU 5-11y, mean 7) • 2 THA • 6 progressive](https://reader034.vdocuments.us/reader034/viewer/2022051814/603755eee76d09229941e1c8/html5/thumbnails/60.jpg)
Kniepijn bij 10 – 16 jarige
![Page 61: Update on femoroacetabular impingement (FAI) · What are Risk Factors for Revision after Hip Arthroscopy for FAI at 7-years ? 52 hips (FU 5-11y, mean 7) • 2 THA • 6 progressive](https://reader034.vdocuments.us/reader034/viewer/2022051814/603755eee76d09229941e1c8/html5/thumbnails/61.jpg)
Kniepijn bij 10 – 16 jarige
![Page 62: Update on femoroacetabular impingement (FAI) · What are Risk Factors for Revision after Hip Arthroscopy for FAI at 7-years ? 52 hips (FU 5-11y, mean 7) • 2 THA • 6 progressive](https://reader034.vdocuments.us/reader034/viewer/2022051814/603755eee76d09229941e1c8/html5/thumbnails/62.jpg)
Epiphysiolyse
• Klachten dikwijls vaag en vaak aan banaal trauma geweten
• Gerefereerde pijn naar de knie
• De typische patient:
• obese jongen tussen 10 en 16
• maar!!…ook magere meisjes
• RX niet altijd overduidelijk
• Goed klinisch onderzoek: heuprotatie!