JAAOS

JAAOS, Volume 21, No. supplement


Clinical Diagnosis of Femoroacetabular Impingement

The diagnosis of femoroacetabular impingement (FAI) syndrome is made based on a combination of clinical symptoms, physical examination findings, and imaging studies. A detailed assessment of each of these components is important to differentiate FAI from other intra- and extra-articular hip disorders. Clinical and physical examination findings must be viewed collectively because no single pathognomonic finding exists for FAI. Nevertheless, common components of the history and physical examination do suggest a diagnosis of FAI.

      • Subspecialty:
      • Adult Reconstruction

    Clinical Outcomes Assessment in Clinical Trials to Assess Treatment of Femoroacetabular Impingement: Use of Patient-reported Outcome Measures

    Patient-reported outcome measures are an important component of outcomes assessment in clinical trials to assess the treatment of femoroacetabular impingement (FAI). This review of disease-specific measures and instruments used to assess the generic quality of life and physical activity levels of patients with FAI found no conclusive evidence to support a single disease-specific questionnaire. Using a systematic review of study methodology, the Copenhagen Hip and Groin Outcome Score and the 33-item International Hip Outcome Tool scored the best. Nevertheless, both of these instruments were developed recently and have not been established in the literature. Although currently used generic and activity-level measures have limitations, as well, they should be considered, depending on the specific goals of the study. Additional research is needed to assess the properties of these measures fully when used to evaluate patients with FAI.

        • Subspecialty:
        • Adult Reconstruction

      Clinical Trials in Orthopaedics and the Future Direction of Clinical Investigations for Femoroacetabular Impingement

      Femoroacetabular impingement (FAI) represents a heterogeneous group of disorders that affect a diverse patient population. The natural history of the disease, the role of nonsurgical management, the indications for surgery, optimal surgical techniques, and the predictors of treatment outcomes need to be further defined. To date, clinical research reports have included primarily surgical case series. Future clinical investigations are needed to establish improved clinical evidence to guide patient care. Most urgent is the need to better understand the potential role of standardized nonsurgical treatment options for FAI and to define the predictors of surgical and nonsurgical outcomes. Future randomized controlled trials and large observational cohort studies targeted at these clinical research deficiencies will strengthen the evidence and improve informed decision making regarding the management of symptomatic FAI.

          • Subspecialty:
          • Adult Reconstruction

        Diagnostic Imaging of Femoroacetabular Impingement

        Imaging studies play a key role in establishing the diagnosis of femoroacetabular impingement (FAI). When clinical examination is suggestive of FAI, radiographic evidence should confirm the diagnosis. Imaging findings must be evaluated in the context of the patient's clinical presentation and recreational activities. Plain radiographic evaluation remains the initial diagnostic modality. Three-dimensional imaging such as MRI and CT often is obtained for the evaluation of labral and cartilage pathology, definition of bony anatomy, and surgical planning.

            • Subspecialty:
            • Adult Reconstruction

          Femoroacetabular Impingement: Defining the Condition and its Role in the Pathophysiology of Osteoarthritis

          Femoroacetabular impingement (FAI) is an increasingly recognized cause of hip pain. It is best defined as a pathologic mechanical process by which morphologic abnormalities of the acetabulum and/or femur combined with vigorous hip motion lead to repetitive collisions that damage the soft-tissue structures within the joint itself. Based on cross-sectional studies in which FAI morphology was studied before the presence of radiographic osteoarthritis (OA), and on prevalence studies in younger, asymptomatic persons, it is clear that FAI and its morphologic risk factors are common in young adult hips and predispose to the later development of OA in certain patients. Longitudinal studies also support the assertion that, in middle-aged adults, the presence of cam deformities at baseline substantially increases the risk of developing OA and the need for total hip arthroplasty. More long-term data are needed to better define the natural history of pincer deformities as well as FAI in younger cohorts.

              • Subspecialty:
              • Adult Reconstruction

            Legg-Calvé-Perthes Disease and Slipped Capital Femoral Epiphysis: Major Developmental Causes of Femoroacetabular Impingement

            Problematic femoroacetabular impingement frequently is seen following Legg-Calvé-Perthes disease (LCPD) in young children and following slipped capital femoral epiphysis (SCFE) in older children and adolescents. Although symptoms may be mild in adolescents and young adults, chondral damage following LCPD and SCFE deformity is cumulative and irreversible, which has led to a recent emphasis on the consideration of early treatment. The surgical dislocation approach and improved MRI and three-dimensional CT have revealed common patterns of deformity and structural damage. The surgical dislocation approach is a superb diagnostic tool unmatched in assessing complex dynamic impingement patterns, and it allows direct treatment of deformity through recontouring of the head and neck and, in unhealed SCFE, epiphyseal realignment. The contemporary hip-preserving management of deformity following LCPD and SCFE is changing rapidly, necessitating careful evaluation of new treatment methods.

                • Subspecialty:
                • Pediatric Orthopaedics

              Motion Analysis, Cartilage Mechanics, and Biology in Femoroacetabular Impingement: Current Understanding and Areas of Future Research

              The effect and interplay of pathomorphology and joint kinematics is increasingly recognized as important in the study of femoroacetabular impingement (FAI). Hip joint kinematics consists of motion analysis at the macroscopic hip joint level. Although overall joint morphology and subject-specific kinematics are important, the cellular mechanobiology of cartilage and the biologic response to cartilage injury are poorly understood and require further study if surgeons are to understand how tissue damage actually occurs. A clearer understanding of these factors may provide the foundation for new treatments that could alter the joint injury associated with FAI. The purpose of this study group was to discuss the current evidence regarding the interaction of hip joint motion, cartilage mechanics, and cartilage biology with FAI and determine future priorities for research in these areas to expand the surgeon's ability to understand and manage this increasingly recognized clinical entity. Specific research needs were identified in four areas: motion analysis (how do muscle contributions to joint loading influence the disease process?), arthrokinematics (what happens at the joint level in vivo?), cartilage mechanics (how do cartilage cells respond to different mechanical stimuli?), and cartilage biology (need to identify biomarkers for cartilage degradation).

                  • Subspecialty:
                  • Adult Reconstruction

                Overview of Treatment Options, Clinical Results, and Controversies in the Management of Femoroacetabular Impingement

                The surgical management of symptomatic femoroacetabular impingement (FAI) generally is indicated after the failure of a trial of nonsurgical treatment. Surgical planning includes an assessment of the labrochondral pathology as well as of the acetabular and proximal femoral bony deformity. Advanced articular cartilage disease generally is associated with poorer outcomes. Surgical hip dislocation and hip arthroscopy have been used, with favorable early outcomes and low complication rates. Careful patient selection is important in predicting the success of the surgical management of symptomatic FAI. A trial of nonsurgical management generally is recommended, but limited information exists regarding its success. The early outcomes of both open and arthroscopic surgical techniques demonstrate significant improvement in most patients, with relatively low rates of complications. Because poorer clinical outcomes are associated with more advanced articular cartilage degeneration, improved strategies for the earlier identification and disease staging of symptomatic patients may enhance the long-term outcomes of both nonsurgical and surgical management.

                    • Subspecialty:
                    • Adult Reconstruction

                  Staging of Hip Osteoarthritis for Clinical Trials on Femoroacetabular Impingement

                  Future clinical trials investigating the natural history and treatment of femoroacetabular impingement (FAI) will require multimodal staging systems for hip osteoarthritis because the optimal system will differ based on the size of the study population, the specific objective in question, and the time frame in which the investigator expects to see the specified end point. Plain radiographs are readily available, low in cost, and of unquestioned validity, but they are relatively insensitive to early joint damage. MRI allows assessment of both bony and soft-tissue pathology within the joint, and it is much more sensitive for early joint damage because cartilage is visualized directly. Biochemical imaging techniques such as delayed gadolinium-enhanced MRI of cartilage, T2 mapping, and T1rho offer the potential to identify biochemical damage to cartilage before the onset of irreversible tissue loss. In the future, biomarkers may allow earlier detection of osteoarthritis before the development of radiographic evidence of disease.

                      • Subspecialty:
                      • Adult Reconstruction

                    The Burden of Hip Osteoarthritis in the United States: Epidemiologic and Economic Considerations

                    Osteoarthritis (OA) is a common and disabling disease. Because of improved treatment of chronic diseases and lower mortality from infectious diseases, the US population is aging, and older Americans are living with disabling conditions, including hip OA. The projected number of older adults with arthritis or other chronic musculoskeletal joint symptoms is expected to nearly double, from 21.4 million in 2005 to 41.1 million by 2030. The burden of hip OA is increasing due to the aging population and the obesity crisis; as a result, the need for total hip arthroplasty (THA) is expected to grow 174%, to 572,000 primary THAs per year by 2030 in the United States. Prior projections appear to have underestimated the actual number of primary and revision THAs that are in demand.

                        • Subspecialty:
                        • Adult Reconstruction

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