Travis G. Maak, MDDepartment of Orthopaedics

Hip & Knee Preservation Service

FAI in the Pediatric Patient

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Hip / Pelvic Pain: Diagnosis

• Average time from injury to accurate diagnosis 21 months

• Average of 3.3 providers seen before definitive treatment

Burnett JBJS 2006

4

Orthopaedic causes Bone/jointFemoroacetabular impingement (FAI) Acetabular labral tearsOsteitis pubisStress fractures: Pubic ramus/femoral neck Degenerative hip joint diseaseAvascular necrosis of the femoral head Slipped capital femoral epiphysisAvulsion fracture: GT/LT/ASIS/AIIS/Ischium

MuscleAthletic pubalgiaHockey player’s syndromeRectus femoris strain/tearAdductor strain/tendonitis/tearIliopsoas strain/tearRectus abdominis strain/tearMuscle contusion Gracilis syndromeSnapping hip syndrome

NeurologicNerve entrapment: Ilioinguinal/obturator neuropathy Lumbar radiculopathy

Other orthopaedicBursitis Bone/soft tissue neoplasm of hip/pelvis Herniated nucleus pulposus Seronegative spondyloarthropathy

Non-orthopaedic causes

Hernia: Inguinal/femoral

GynecologicEndometriosisPelvic inflammatory disease Ovarian cyst

GastrointestinalRectal/colon neoplasm Inflammatory bowel disease Diverticulitis

Osseous Pathology

• Femoroacetabular Impingement

• Dysplasia

• Extraarticular Impingement

• Ischiofemoral / Greater Trochanteric

• Supra-acetabular (post-avulsion)

• Femoral Neck Stress Fracture

• Avulsion Fractures

• Osteitis Pubis

• Sacroilitis

Static Factors

• Abnormal stress and asymmetric load between the femoral head and acetabular socket in the axially-loaded position• insufficient head-socket congruency• asymmetric wear of the acetabular and femoral head chondral surfaces• reactive hip pain +/- hip instability

• Dysplasia: Anterior or lateral undercoverage of acetabulum, Femoral anteversion, Femoral valgus (Coxa Valga)

• Focal / Diffuse chondral loss• Legg-Calve-Perthes Disease• Slipped Capital Femoral Epiphysis (SCFE)

Legg-Calve-Perthes Disease

§ Prognosis– 50% do well with

conservative treatment– Delayed DJD from aspherical

joint

§ Age is important!!– >8 years old, poor prognosis

§ Treatment– Keep hip contained

• Abduction• Femoral/pelvic

osteotomies

Slipped Capital Femoral Epiphysis “SCFE”§ Posterior and inferior slipping of epiphysis relative to

the metaphysis from shear stress.§ Age: 10-17 y.o. w/ obesity§ Consider concomitant endocrine abnormalities§ Bilateral 20-40%

Slipped Capital Femoral Epiphysis

§ H&P– Grain pain (sometimes knee) with limp or inability to WB

§ Stable– Limp– +/- pain

§ Unstable– Inability to bear weight– Acute onset of severe pain– Worse prognosis

• Osseous necrosis

Seattle Childrens’Hospital

Treatment

Acetabular Dysplasia Focal Chondral Defect Diffuse Chondral Loss

Dynamic Factors

• Abnormal stress and contact between the femoral head and acetabular rim during hip motion• Abnormal engagement between the femoral head and acetabulum• Reactive hip pain with hip flexion & extension activities

• Femoroacetabular Impingement (FAI): • Loss of offset and sphericity of femoral head-neck junction (Cam)• Acetabular overcoverage (Pincer)• Femoral retroversion • Femoral varus (Coxa vara)

Normal

Cam

Pincer

Combo

Compensatory Injury

• Sports hernia & Athletic pubalgia• Osteitis Pubis• Sacroiliitis• Muscle Injury• Posterior hip subluxation

Physical Exam Maneuvers

Passive Impingement & Apprehension Tests

• FADIR (A): Anterior pain indicates classic FAI

• Superolateral Impingement Test (B): Flexion and ER

• Posterior Rim Impingement Test (C): Extension, abduction, and ER

• Lateral Rim Impingement Test (D): Abduction with neutral rotation

A B

C D

History & Exam

• Femoroacetabular Impingement

• Acetabular Dysplasia

• Femoral Neck Stress Fx

• Internal Snapping Hip (Psoas)

• External Snapping Hip (TFL/ITB)

• Greater Trochanteric Bursitis / Pain

• Avulsions (ASIS/AIIS/Ischium)

• Adductor tear

• Sports Hernia / Athletic Pubalgia

Ø Sitting groin pain, +FADIR

Ø Standing groin pain, +instab

Ø Groin pain w/ axial load

Ø Groin pop, + Stinchfield

Ø Lateral pop, TTP at GT

Ø TTP at GT

Ø Eccentric load and pain

Ø Forced eccentric abduction

Ø Groin/low abd pain w/ sit-up

Diagnosis History & Exam

§ More common in dancers, gymnasts, figure skating, or other

sports that require a high degree of hip ROM

§ Commonly have concomittant hip pathology

– Internal & External Snapping Hip (Coxa Saltans)

– Psoas Tendinitis / Greater Trochanteric Bursitis

– Sensations of “instability” with supraphysiologic motion

§ Careful Hx, PE & Check Beighton Criteria

§ FAI can occur with minimal osseous pathology due to both

subspine and true FAI in supraphysiologic flexion positions

§ Always start with conservative measures

§ Surgical intervention may be indicated but ensure that

careful capsular repair is performed.

§ DO NOT TOUCH the psoas tendon

The Hypermobile Hip

Weber Sports Heath 2015

Plain Radiographs

• AP Pelvis• 45 or 90 Degree Dunn Lateral• False Profile Views

• High cross over of hip dysplasia in young patients with hip pain

Normal: <50 degrees (42-68)Parvizi et al, JAAOS 2007, Tannast et al, AJR 2007, Notzli JBJS Br 2000/2002

Alpha Angle

Coronal Sagittal

Axial

MRI

§ Make sure that comprehensive pre-operative imaging is present to fully understand the osseous morphology

§ Pincers or borderline dysplasia – Get a CT§ Make sure you calculate your angles and have a clear

game plan

Know your enemy…

CT Scan

• Evaluate• Acetabular version (clock face)• Midcoronal & midsagittal CEA• Femoral version• Neck-shaft angle• Maximum alpha angle (clock face)• AIIS morphology

• Obtain radial sequencing through femoral head-neck axis

• Get 3D reconstructions

Cam + Normal Acetabular Coverage

Normal LCEA with severe anterior undercoverage

Rim Evaluation

-13-1

+9

CT Scan

Radial sequencing through femoral head-neck axis

• 474 hips in 237 symptomatic patients with CT scans obtained for other reasons (abdominal trauma / abdominal pain)

• Excluded dysplasia (LCEA <20�) or profunda (LCEA >40�)• Mean LCEA: 31• 15% had isolated cranial retroversion (+crossover)• 30% had < 50% posterior coverage (+ posterior wall)• Males had significantly higher crossover (25% vs. 11%) & posterior wall

signs (53% vs. 13%)• Cranial retroversion (+ crossover) and a positive posterior wall sign may

be normal variants

Is There Evidence?

Treatment

• Medicine– NSAIDs– Glucosamine/Chondroitin

Sulfate• Activity Modification• Physical Therapy• Injections

– Extra-articular– Intra-articular

• Steroid• Viscosupplementation

• Surgery

Activity Modifications

§ Squatting, lunging§ Sitting ergonomics§ Getting in and out of a car§ Avoidance of aggravating activities§ No combined movements of

flexion, adduction and Internal rotation

Lewis Phys Ther 2006 Emara J Orthop Surg 2011

Physical Therapy§ Therapeutic Modalities § Addressing pelvic alignment

– Pelvic obliquities, Posture§ Stretching§ Core and hip stabilization/strengthening § Functional movement/Muscle re-education§ Manual therapy

Cashman JOSPT 2014Cook JOSPT 2009Reiman IJSPT 2013Wright Man Ther 2012

IA Injection

• Both diagnostic and therapeutic• Exacerbate symptoms prior to and

document symptom relief post injection• Include both % and duration of relief

• Poor / No relief may be suggestive of extra-articular pathology

• Particularly useful in patients with concomitant lumbosacral pathology

• MRI Arthrogram is NOT a substitute

§ Arthroscopic approach with pincer or combined pincer and CAM impingement

– Mean age 31 y/o (debridement) & 27 y/o (repair)– Labral debridement (36 pts) mean f/u 3.5 yrs

• HHS 88.9, 68% G to E– Labral repair (29 pts) mean f/u 16.5 months

• HHS 94.3, 92% G to E– Conclusion

• Labral repair significantly improves clinical outcomes

Labral Repair

Larson et al AJSM 2012

Labral Repair

§ Systematic review of 11 studies§ Mean f/u 3.2 years§ Conversion to THA ranged from 0-26%§ Reduced pain and improvement in hip function in all

studies§ 68-96% improved function and pain relief

Femoral & Acetabular Osteochondroplasty

Clohisy JC CORR 2010

§ Arthroscopic management first suggested by Leunig et al in 2010

§ Chen 2014– 34 hips (10-19 y/o)– Significant improvement in alpha angle & IR in flexion– Complete pain relief in 88% of patients– Not indicated for severe deformity (prox fem osteotomy)

§ Wylie 2015– 9 hips (13.5-26.9 y/o)– HHS (64à91)– HOS Sports (53à89)

FAI and SCFE

Leunig CORR 2010 Chen Arthroscopy 2014 Wylie Arthroscopy 2015

17 y/o Football Player w/ Groin Pain

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Femoral Osteochondroplasty

Hip pain-Return to Sport considerations§ Strength, coordination, reaction time, and

proprioception time should be assessed at regular intervals

§ RTP when affected hip conditioning is 90% of contralateral hip

§ Little evidence but…§ Kivlan et al systematic review showed that there are

tests that are reliable and valid for determination of return to sport after hip injury

– Single leg squat– Single leg stance– Deep squat– Star excursion/Y balance test

Maak AAOS ICL 2013Kivlan IJSPT 2012

Thank You

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