Epidemiology Femoroacetabular impingement

Epidemiology Femoroacetabular impingement

Femoro-acetabular impingement FAI also known as hip impingement is characterized by excessive contact between the proximal part of the femur and acetabulum.12 A difference can be made between two different types. The so-called Cam and Pincher impingement.
Cam type The Cam type is characterized by an abnormal morphology localized at the anterior lateral side at the height of the transition from the collum to the femoral head. This abnormality results in a reduced depth of the femoral head in the acetabulum, with the result that the femoral head is forced to press against the acetabulum during movement. Due to this excessive compression there may be osteochondral injury or a lesion of the fibrocartilaginous triangular labrum arise. This lesion occurs mostly along the anterior and supero lateral edge of the acetabulum. Causes of Cam impingement are abnormalities of the epifysair disk, an enlarged hip range of motion (ROM), post-traumatic situations, rigorous exercise, a malunion or genetic abnormalities.5,10,12,19
Pincher type The Pincher type is characterized by an excessive anterolateral femoral head coverage because of an abnormal morphology of the acetabulum. Because of this abnormality, friction arises during movement between the femoral head and the prominent edge of the acetabulum. This friction casus microtrauma, which eventually can lead to degeneration or a lesion of the labrum, cyst formation and calcification. Degeneration and lesions of the labrum mainly occur where the power and transmission is greatest. This is the anterior and superolateral portion of the labrum. Causes for a pincher impingement are a coxa profunda, coxa vara, acetabular protrusion, and acetabular retroversion.5,10,19
Treatment The difference between the two types is of major importance in relation to different treatment techniques.12 FAI is seen as a cause for secondary osteoarthritis of the articulatio coxae6,8
Etiology It often occurs in professional athletes, runners, and other people doing intensive sports. Athletes with repetitive hip rotation, as in the practice of golf, football and karate are at risk.2,4,5,6,7,19
Age FAI usually affects active persons in the (>40) fourth decade of life.2,4,5,6,7,19
Sex According to M. Keogh J. et al and Pfirmann W. et al, the prevalence of FAI is higher in men than in women.5,12 The articles didn’t have percentages listed. Leibold R. M. et al mentions a prevalence of 60% among women and 40% in men.7Significantly more men had a CAM type and more women had a Pincher type.12
Pain location Hip joint
Symptoms According to Clohisy J. C. et al 73% of the patients experienced the pain as sharp, 73% as itchy and 25% as burning. In 46% of the cases the pain is constantly expierenced , in 42% of cases the pain is expierenced as intermittent. 65% of patients experience a mechanical symptom, which a “pop” sensation in 65% and a snap in 46% of the cases.2 Zebala L. P. et al is talking about a ‘giving way’ and ‘lock complaints “as mechanical symptoms. In this article no percentages were given.19Clohisy J.C. et al mentions a rate of 88 patients with groin pain in his article, 67% lateral hip pain and 29% had pain in the gluteal region. ² According to Zebala L. P et al, groin pain, pain in the lumbar and gluteal region are the most common. According to Clohisy JC et al, in daily life, 71% of patients have complaints in activities.19
History of injury According to Clohisy J.C. et al ² Leibold R. M. et al, in 30% of the cases, the cause is unknown, 26% is caused after a trauma and 44% is caused by degeneration.7The symptoms are primarily intermittent, especially after sports activities. The symptoms may increase in frequency as the damage to the labrum and the degeneration of the joint increase.19

Clohisy J.C. et al mentions a rate of 88 patients with groin pain in his article, 67% lateral hip pain and 29% had pain in the gluteal region. ² According to Zebala L. P et al, groin pain, pain in the lumbar and gluteal region are the most common. According to Clohisy JC et al, in daily life, 71% of patients have complaints in activities.19

Provocation Provocative activities are running 69%, sitting 65%, walking 58% and standing in 44% of the patients.² According to Kuhlman G. S. et al patients experience problems with getting up from the chair, sitting a long time, in and out of the car and leaning forward.6
Pathology FAI is a pathology that has multiple inaccurate or delayed diagnosis. An average patient has his or her first symptoms for around 3.1 years (range 3 months – 15 years). Patients visited an average of 4.1 specialists (range 1-16) before the diagnosis of FAI is made​​. These specialists include chiropractors, orthopedic surgeons and neurologists. A rapid accurate diagnosis is beneficial for higher surgical success rate and can prevent osteoarthritis. The diagnosis of FAI is complicated because the clinical picture of this patient corresponds with other pathologies. Because of this, the list of differential diagnoses around FAI are very large (see Table 1).2

Tabel 1: Differential diagnosis6,7
* Avascular caput femoris necrosis* Bursitis

* Canker

* Inguinal hernia
* Arthritis
* Intra-articular loose cartilage
* Hip dysplasia

* Stress fracture
* Crohn’s Disease
* Local nerve entrapment
* Perthes Disease
* Osteoarthritis
* Lumbar pathology (hernia / degeneration)
Literature 2. Clohisy J. C., Knaus E. R.,Hunt D. M. , Lesher J. M., Marcie Harris Hayes. Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement. Clin Orthop Relat, volume 467, number 3, march 2009, 638–644.

4. Guishan G. U., ZHU Dong, WANG Gang, WANG Chengxue. Roles of radiograph,magnetic resonance imaging, threedimensional computed tomography in early diagnosis of femoro acetabular impingement in 17 cases. Chinese Journal of Traumatology 2009, 375?378.

5. Keogh M. J., Batt M. E., A Review of Femoroacetabular Impingement in Athletes. Sport Med 2008: 38, 863 – 878.

6. Kuhlman G., Domb B. Hip Impingement: Identifying and Treating a Common Cause of Hip Pain. American family physican, volume 80, number 12, December 2009, 1429?1434.

7. Leibold R. M., Huijbregts P. A., Jensen R. Concurrent Criterion Related Validity of Physical Examination Tests for Hip Labral Lesions: A Systematic Review. The journal of manual & manipulative therapy volume16, number 2, 24 – 41.

8. Leunig M., Beaule P., Reinhold Ganz. The Concept of Femoroacetabular Impingement Current Status and Future Perspectives. Clin Orthop, volume 476, number 3, march 2009, 616–622.

10. Neumann M., Quanjun C., Klaus A., Siebenrock, B. Impingement free Hip Motion The ‘Normal’ Angle Alpha after Osteochondroplasty. Clin Orthop, volume 467, number 3, march 2009, 699–703.

12. Pfirmann W., Mengiardi B., Dora C., Kalberer F., Zanetti M., Hodler J. Cam and Pincer Femoroacetabular Impingement: Characteristic MR Arthrographic Findings in 50 Patients. Radiology Volume 240, Number 3, September 2006, 778 – 785.

19. Zebala L. P., Schoenecker P. L., Clohisy J. C. Anterior Femoroacetabular Impingement: A Diverse Disease with Evolving Treatment Options. The Iowa Orthopaedic Journal, volume 27, 71?81.

 

Physical examination:

The literature discusses the specific testing of FAI in detail. Kuhlman G. S. Clohisy et al, and J. C. et al are the only ones who make a recommendation for the inspection and palpation during physical examination. When inspecting the hip a common sign of Trendelenburg (33%) should be given.6 Active and passive asymmetric deviations between both hips should also be examined.2 Sensitivity to the posterior side while palpating may indicate a bursitis which may be associated with an intra-articular problem. This test has a sensitivity of 0.8 and a positive predictive value of 1.00. The specificity and negative predictive value for this test could not be calculated related data insufficiency.6
In examining the hip mobility patients experienced pain in both the active and passive flexion, adduction and internal rotation. The ROM is mainly limited in flexion and internal rotation. Clohisy J. C. et al mentions a 97° flexion and internal rotation in 90° of 9°.
In this research, a minimal ROM difference between was found between the symptomatic and asymptomatic side (Table 2). In comparison with the normal ROM of the hip there will be a significant difference.2 Articles described the use of different tests. Table 3 gives an view of the various tests and the corresponding implementation.
Table 2: Summary of the ROM7
Momvement Symptomatic side Asymptomatic side
FlexionExtension

Abduction

Adduction

Endorotation (neutral)

Exorotation (neutral)

Endorotatie (90° flexion)

Exorotation (90° flexion)

97°4°

38°

17°

15°

26°

28°

101°4°

38°

19°

18°

27°

12°

30°

Table 3 FAI Tests
Test Performance Positive Literature
(Anterior) Impingement / FADIR test Pt. lies on back, 90° flexion, adduction and endorotation Provocation of groin pain 2,6,7,17
FABER test / Patrick Sign Pt. lies on back, passieve abductie en exorotatie Provocation of groin pain 2,6,7,17
Impingement provocation test/ posterior impingement test Pt. lies on back hyperextension, adduction and exorotation Provocation of groin pain 2,7
Resisted Straight leg raise Pt. lies on back 30 actief flecteren en weerstand van Ft tegenhouden Provocation of groin pain 2,17
Log roll test Pt. lies on back, rolling the leg back and forth. Provocation of groin pain 2,6
Imaging:
The imaging examination FAI, consists of, Röntgen, computer tomography (CT), magnetic resonance imaging (MRI) and magnetic resonance arthrographie (MRA).
Kuhlman G. S. et al recommends radiography in patients whose history and physical examination suggest FAI. These radiological picture is looking at a possible hip dysplasia, osteoarthritis or abnormal posterolateral orientation of the labrum. It can also look for necrosis or exostosis of the femoral caput and femoral collum, arthritis of the SI joint and the lumbar spine. Kuhlman G.S. et al advises the labrum to be assessed by the use of a MRA. An MRI without arthrography has a sensitivity of 25 to 30% to diagnose a labral lesion. This sensitivity increases up to 92%, when a MRA is used.6
Pollard T. C.B. et al mentions the calculation of the alpha angle and anterior offset ratio (AOR) to diagnose FAI in his article. A cross-table lateral view is recommended. From the article of Pollard T. C. B. et al, it is clear that an alpha angle of an average population lies between 46° and 49°. The AOR lies between 0:18 and 0:20. Patients with a CAM FAI alpha angle of more than 63° and a AOR smaller, or equal to 0.15.13 In the article by Neumann M. et al the alpha angle in normal people is 43° and in patients with FAI is 66°.10
According Pfirmann W. et an MRA can detect abnormalities of a labrum, cartilage damage, and bony deformities of the acetabular edge can be viewed and judged. He concluded that significantly more men had a CAM type and more women had a Pincher type. The alpha angle was significantly greater in patients with FAI than in the control group. These were, respectively, 72° and 55°.12
The acetabular depth is deeper in a CAM type impingement, 6 mm. A Pincher type impingement this is 5 mm. The bony abnormalities were not significantly different between both groups.12
 Literature 2. Clohisy J. C., Knaus E. R.,Hunt D. M. , Lesher J. M., Marcie Harris?Hayes. Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement. Clin Orthop Relat, volume 467, number 3, march 2009, 638–644.

6. Kuhlman G., Domb B. Hip Impingement: Identifying and Treating a Common Cause of Hip Pain. American family physican, volume 80, number 12, December 2009, 1429?1434.

7. Leibold R. M., Huijbregts P. A., Jensen R. Concurrent Criterion?Related Validity of Physical Examination Tests for Hip Labral Lesions: A Systematic Review. The journal of manual & manipulative therapy volume16, number 2, 24 – 41.

10. Neumann M., Quanjun C., Klaus A., Siebenrock, B. Impingement?free Hip Motion The ‘Normal’ Angle Alpha after Osteochondroplasty. Clin Orthop, volume 467, number 3, march 2009, 699–703.

12. Pfirmann W., Mengiardi B., Dora C., Kalberer F., Zanetti M., Hodler J. Cam and Pincer Femoroacetabular Impingement: Characteristic MR Arthrographic Findings in 50 Patients. Radiology Volume 240, Number 3, September 2006, 778 – 785.

13. Pollard T. C. B., Villar R. N., Norton M. R., Fern E. D., Williams M. R., Simpson D. J., Murray D. W., Carr A. J. Femoroacetabular impingement and classification of the cam deformity: the reference interval in normal hips. Acta Orthopaedica 2010; 81 1 – 8

17. Troelsen A., Mechlenburg I., Gelineck J., Bolvig L., Jacobsen S., Søballe K. What is the role of clinical tests and ultrasound in acetabular labral tear diagnostics. Acta Orthopaedica 2009, 314–318

 

 

Evidence based practice

According to Clohisy J. C. et al the outcome of his research that 98.7% of patients with FAI tests positive on the FABER / Patrick test. 88.6% tests positive on an anterior impingement / Fadir test and 56.1% tests positive on resisted straight leg raise test. For the log roll test and posterior impingement test this was 30% and 21.2%. This article does not address any other statistical values​​.2
Study Test Sensitivity (Show)
Clohisy J. C. et al 2 Faber test 98.7%
Anterior impingement / Fadir test 88.6%
Straight leg raise test 56.1%
log roll test 30%
posterior impingement test 21.2%
Kuhlman G. S. et al recommends the FABER / Patrick test, the anterior impingement test / Fadir test and the log roll test in his article. This article does not address statistical values​​.6
In the article of Troelsen A. et al the anterior impingement / Fadir test, FABER / Patrick’s’s test and resisted straight leg raise test were used. There is a sensitivity of 59%, specificity of 100%, positive predictive value of 100% and a negative predictive value of 13% for the anterior impingement / Fadir, test. For the FABER / Patrick’s test the sensitivity is 41%, specificity 100%, positive predictive value 100% and a negative predictive value of 9%. No values ​​for the resisted straight leg raise test were mentioned because they were not worth mentioning according to the author.17
Study Test Sensitivity (Show) Specificity (Exclude)
Kuhlman G. S. et al 6,17 Anterior impingement / Fadir test 59% 100%
FABER / Patrick’s’s test 41% 100%
resisted straight leg raise test NT NT
Leibold M.R. et al writes in his conclusion, that a negative test result for the anterior impingement test / Fadir test, the flexion-internal rotation test, the impingement provocation / posterior impingement test and the flexion – adduction – axial compression test or a combination of these tests can exclude a labrum lesion. According to his article, there is no good test for the detection of a labral lesion. Leibold M.R. et al mentions an average sensitivity, and positive predictive value of 0.98 and 0.93 for the anterior impingement / Fadir test. The flexion-internal rotation test has an average sensitivity and positive predictive value of 1.00 and 0.87. For the impingement provocation / posterior impingement test Leibold M.R. et al mentions a sensitivity and positive predictive value of 1.00 and 0.82. For the flexion-adduction-axial compression test the value are both 1.00. No specificity and negative predictive values were mentioned in all tests because it could not be calculated because of insufficiency data.7
Leunig M. L. et al advises the non-arthritic hip score, WOMAC or the Hip outcome score questionnaires that have recently been developed or have been validated for the use in FAI. For these questionnaires there were statistical values mentioned​​.8
Literature 2. Clohisy J. C., Knaus E. R.,Hunt D. M. , Lesher J. M., Marcie Harris?Hayes. Clinical Presentation of Patients with Symptomatic Anterior Hip Impingement. Clin Orthop Relat, volume 467, number 3, march 2009, 638–644.

6. Kuhlman G., Domb B. Hip Impingement: Identifying and Treating a Common Cause of Hip Pain. American family physican, volume 80, number 12, December 2009, 1429?1434.

7. Leibold R. M., Huijbregts P. A., Jensen R. Concurrent Criterion?Related Validity of Physical Examination Tests for Hip Labral Lesions: A Systematic Review. The journal of manual & manipulative therapy volume16, number 2, 24 – 41.

8. Leunig M., Beaule P., Reinhold Ganz. The Concept of Femoroacetabular Impingement Current Status and Future Perspectives. Clin Orthop, volume 476, number 3, march 2009, 616–622.

17. Troelsen A., Mechlenburg I., Gelineck J., Bolvig L., Jacobsen S., Søballe K. What is the role of clinical tests and ultrasound in acetabular labral tear diagnostics. Acta Orthopaedica 2009, 314–318.

 

 

 

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