Femoroacetabular impingement in adolescents and young adults an update

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1 U N I V E R S I T E T E T I B E R G E N Femoroacetabular impingement in adolescents and young adults an update Lene Bjerke Laborie, MD, PhD Paediatric Radiology Department, Haukeland University Hospital Bergen, Norway Associate Professor, Department of Clinical Medicine, University of Bergen

2 No conflicts of interest or commercial disclosures

3 Key Notes Anatomical and pathological mechanisms Radiological assessment Aetiology Epidemiology Management

Femoroacetabular Impingement (FAI) Abnormal relationship: proximal femur - acetabulum Hip pain and early degenerative change Ganz, Parvizi, Beck, Leunig, Notzli, Siebenrock.

4 Femoroacetabular Impingement (FAI) Abnormal relationship: proximal femur - acetabulum Hip pain and early degenerative change Ganz, Parvizi, Beck, Leunig, Notzli, Siebenrock. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orth Relat Res 2003 Ito, Minka, Leunig, Werlen, Ganz. Femoroacetabular impingement and the cam-effect. A MRI-based quantitative anatomical study of the femoral head-neck offset. J Bone Joint Surg Br 2001

5 Challenging diagnosis Clinical and radiological criteria Long-standing hip pain Reduced hip motion Internal rotation and flexion Positive test for anterior impingement

6 A: Normal A B: Cam-type C: Pincer-type B C Tannast, Siebenrock, Anderson. Femoroacetabular impingement: radiographic diagnosis--what the radiologist should know. AJR Am J Roentgenol 2007

7 Standardised AP view, preferably weight-bearing Tilt and Rotation Lateral view CT scan, MRI, MRI arthrography Tannast, Siebenrock, Anderson. Femoroacetabular impingement: radiographic diagnosis--what the radiologist should know. AJR Am J Roentgenol 2007 Meyer, Beck, Ellis, Ganz, Leunig. Comparison of six radiographic projections to assess femoral head/neck asphericity. Clin Or Relat Res 2006 Clohisy, Carlisle, Beaule, et al. A systematic approach to the plain radiographic evaluation of the young adult hip. J Bone Joint Surg Am 2008

8 Cam-type Pistol-grip Deformity Focal prominence Flattened lateral head Siebenrock, Wahab, Werlen, Kalhor, Leunig, Ganz. Abnormal extension of the femoral head epiphysis as a cause of cam impingement. Clin Orthop Relat Res 2004

9 Alpha angle Notzli, Wyss, Stoecklin, Schmid, Treiber, Hodler. The contour of the femoral head-neck junction as a predictor for the risk of anterior impingement. J Bone Joint Surg Br 2002.

10 Cam-type Lateral frog-leg view Antero-posterior (AP) view

11 Pincer-type Posterior wall sign (PWS) Cross-over sign (COS) Excessive acetabular coverage Ganz, Parvizi, Beck, Leunig, Notzli, Siebenrock. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clin Orth Relat Res Jamali et al. Anteroposterior pelvic radiographs to assess acetabular retroversion: high validity of the "cross-over-sign". J Ort Res Reynolds, Lucas, Klaue. Retroversion of the acetabulum. A cause of hip pain. J Bone Joint Surg Br 1999

12 Idiopathic Slipped capital femoral epiphysis (SCFE) Perthes disease (CLP) Other Other risk factors: Increased BMI Age Race Genetics Heavy workload Certain sport activities during growth Murray. The aetiology of primary osteoarthritis of the hip. Br J Radiol 1965 Harris. Etiology of osteoarthritis of the hip. Clin Orthop Relat Res 1986 Stulberg. Unrecognized childhood hip disease: a major cause of idiopathic osteoarthitis of the hip. Proc 3rd meeting The Hip Society. Mosby 1975 Murray, Duncan. Athletic activity in adolescence as an etiological factor in degenerative hip disease. J Bone Joint Surg Br 1971 Pollard, Villar, Norton et al. Genetic influences in the aetiology of femoroacetabular impingement: a sibling study. J B J Surg Br 2010

13 Cam development in high-level athletes during skeletal maturation Increased stress on femoral physis? Ice-hockey, basketball, possibly soccer Cam deformity recognisable and present from age 13 years Gradual development of cam lesion during skeletal maturation Siebenrock et al. Abnormal extension of the femoral head epiphysis as a cause of cam impingement. Clin Orthop Relat Res 2004 Siebenrock et al. Cam-type deformity of the proximal femur arises in childhood in response to vigorous sporting activity. Clin Ort Rel Res 2011 Philippon et al. Prevalence of Increased Alpha Angles as a Measure of Cam-Type Femoroacetabular Impingement in Youth Ice Hockey Players. Am J Sports Med Nepple et al. What is the association between sports participation and the development of proximal femoral cam deformity? A systematic review and meta-analaysis. Am J Sports Med Agricola et al. The development of cam-type deformity in adolescent and young male soccer players. Am J Sports Med Agricola et al. A cam deformity is gradually acquired during skeletal maturation in adolescent and young male soccer players: a prospective study with minimum 2-year follow-up. Am J Sports med

14 Male ice-hockey player, 21 yrs old Courtesy of Dr. Erik Vang, Head Senior Consultant, Musculoskeletal radiologist, Betanien Hospital, Bergen, Norway

15 SCFE, female, 40 yrs Perthes, boy 12 yrs

16 Age - Gender - Race Radiological and Clinical assessment Definition of disease Clinical symptoms in up to 15% of healthy adult population Positive impingement test in population-based study of 19 year-olds: 7.3% of males, 4.7% females Leunig, Ganz. [Femoroacetabular impingement. A common cause of hip complaints leading to arthrosis]. Unfallchirurg 2005 Laborie, Lehmann, Engesæter, Rosendahl. Is a Positive Femoroacetabular Impingement Test a Common Finding in Healthy Young Adults? Clin.Orthop Relat Res. 2013;

17 Norway: -Cam-type: 35% of Males, 10% of Females (AP and frog-leg, 874 M, 1207 F, 19 yrs) -Alpha angle: Higher cut-off values, Gender-specific values Denmark: Cam-type: 17% of Males, 4% of Females (only AP view, 1184 M, 2018 F, yrs) USA: Cam-type: 24% Boys, 10% Girls (Pelvic CT, 276 M, 282 F, (average 14) yrs) Laborie, Lehmann, Engesæter, Eastwood, Engesæter, Rosendahl. Prevalence of radiographic findings thought to be associated with femoroacetabular impingement in a population-based cohort of 2081 healthy young adults. Radiology 2011 Laborie, Lehmann, Engesæter, Sera, Engesæter, Rosendahl. The alpha angle in cam-type femoroacetabular impingement new reference intervals based on 2038 healthy young adults Bone and Joint Journal, 2014 Gosvig, Jacobsen, Sonne-Holm, Gebuhr. The prevalence of cam-type deformity of the hip joint: a survey of 4151 subjects of the Copenhagen Osteoarthritis Study. Acta Radiol 2008 Li, Helvie, Mead, Gagnier, Hammet, Jong. Prevalence of femoroacetabular impingement morphology in asymptomatic adolescents.. J Pediatr Orthop 2015.

18 Non-operative management Surgery - Ongoing debate Arthroscopic surgery vs. Open surgery with femoral head dislocation, or a combination of the two surgical methods Arthroscopic surgery prefered treatment in pediatric population Clohisy, St John, Schutz. Surgical treatment of femoroacetabular impingement: a systematic review of the literature. Clin Orth Relat Res 2010 Pathy, Sink. Femoroacetabular Impingement in children and adolescents. Review. Curr Opin Pediatr 2016

19 Future perspectives High-level sports activity during growth may be a new and distinct risk factor for a cam-type deformity. Further research needed. Radiographic markers and values associated with FAI are not established in the paediatric population Composite scoring system: Clinical and radiological markers Further studies in the paediatric population are required Genetic aspects

20 --THANK YOU--

Adolescent Femoroacetabular Impingement (FAI): Gender Differences in Hip Morphology

Adolescent Femoroacetabular Impingement (FAI): Gender Differences in Hip Morphology Perry Hooper, DO Sameer Oak, MD Gehan Ibrahim, MD T. Sean Lynch, MD Ryan Goodwin, MD James Rosneck, MD International