Femoroacetabular impingement types .pptx

femoroacetabular impingement

1. Femoroacetabular impingement DR C SUBASH CHANDIRABOSE FINAL YEAR POST GRADUATE MADRAS MEDICAL COLLEGE

2. Abnormal pressure relationship between the femoral head and acetabulum DEFINITION

3. types C am Type Pincer Type Mixed

4. CAM type Impingement results from femoral head or head-neck abnormality.

5. PINCER TYPE Impingement results from overcoverage of the femoral head by the acetabulum

6. MIXED TYPE Cam and Pincer type coexist in the same hip Most common type

7. Etiology ABNORMAL ACETABULUM Acetabular retroversion Coxa profunda Protrusio acetabuli

8. ETIOLOGY ABNORMAL SHAPE OF FEMORAL HEAD Slipped capital femoral epiphysis Femoral head flattening in avascular necrosis Femoral retroversion Coxa vara

9. ETIOLOGY CHILHOOD DISORDERS Developmental dysplasia of hip Slipped capital femoral epiphysis Perthes disease OTHERS Normal hip anatomy with excessive hip range of motion Iatrogenic disorders like previous osteotomies of Acetabulam and femur

10. CLINICAL FEATURES Groin pain with activity Locking of the hip often with sharp pain when rising from a hyperflexed sitting position or from prolonged sitting Reduced hip flexion and Internal rotation

11. FADIR TEST

12. FABER TEST

13. HABER TEST

14. RADIOGRAPHS Standardized AP pelvis radiographs with the legs internally rotated 15° Cross Table lateral view 45° Dunn lateral view Frog-leg lateral

15. CROSSOVER SIGN  

16. POSTERIOR WALL SIGN

17. ISCHIAL SPINE SIGN

18. Pistol grip deformity

19. Anterior head neck offset ratio 1 2 3 Ratio = distance between 2 nd & 3 rd line / diameter of femur head Value of less than 0.15 - impingement

20. ALPHA ANGLE N ormal value for the alpha angle to be 42 degrees Asess D egree of asphericity at the femoral head neck junction. More than 50 to 55 degrees consistent with a cam deformity

21. LATERAL CENTER EDGE ANGLE Normal 25 – 35 degree Less than 20 degrees is indicative of hip dysplasia More than 40 degrees display overcoverage

22. Anterior center edge angle of lequesne False profile view Less than 20 degree undercoverage

23. TONNIS ANGLE Normal Tonnis angle between 0° and 10 More than 10 degrees are present with hip dysplasia Less than 0 degrees can indicate overcoverage

24. Beta angle Less than 30 degrees is indicative of impingement

25. Ct scan

26. MR ARTHROGRAPHY

27. dGEMRIC

28. MANAGEMENT NONOPERATIVE Activity modification Non-steroidal anti-inflammatory medication Hip muscle strengthening exercises Avoid Range of motion exercises

29. Goals of surgery Eliminate abnormal contact between proximal femur and acetabulum Address labral and articular cartilage damage To prevent the progression of Osteoarthritis Hip

30. indications for surgery Femoral head-neck offset deformity alpha angle >55° and acetabular retroversion MRI with labral pathology Failure of nonoperative management Associated with Clinical Symptoms

31. OPERATIVE MANAGEMENT Open surgery Arthroscopic Combined

32. SURGICAL DISLOCATION OF THE HIP Kocher-Langenbeck incision Trochanteric osteotomy Protects the profundus branch of the medial femoral circumflex artery

33. a Reflect the labrum Osteochondroplasty of Acetabulum Osteochondroplasty of the femoral head-neck junction Up to 30% of the diameter of the femoral neck can be removed

34. POSTOPERATIVE CARE Toe touch weight bearing for 6 weeks After 6 weeks weight bearing is allowed with progressive abductor strengthening Low-molecular-weight heparin is used for 2 weeks followed by aspirin 325 mg per day for another 4 weeks.

35. PERIACETABULAR OSTEOTOMY Indications  Pin cer-type impingement caused by global acetabular retroversion

36. exposure

37. Ischial osteotomy 1 cm below the inferior lip of the acetabulum with its tip aimed at the ischial spine

38. superior pubic ramus osteotomy Osteotomize the superior pubic ramus perpendicular to its long axis just medial to iliopectineal eminence

39. Supra-Acetabular Osteotomy 1 cm above the iliopectineal line towards the apex of sciatic notch

40. Osteotomy of posterior column Iliopectineal line, through the medial quadrilateral plate, and parallel to the sciatic notch directed toward the ischial spine .

41. Mobilization of the Acetabular Fragment Internally rotate extend adduct

42. fixation Proximal to distal through the ilium and into the fragment in a divergent pattern Anterior to posterior from the anteroinferior iliac spine to inferior portion of the ilium

43. POSTOPERATIVE CARE Toe touch weight bearing for 6 weeks Range of motion is limited for the first 6 weeks After 6 weeks weight bearing is allowed with progressive abductor strengthening Low-molecular-weight heparin is used for 2 weeks followed by aspirin 325 mg per day for another 4 weeks.

44. Hip Arthroscopy

45. COMBINED HIP ARTHROSCOPY AND LIMITED OPEN OSTEOCHONDROPLASTY The advantage of this approach is primarily avoiding larger exposure including trochanteric osteotomy Only the anterior aspect of the femoral head and neck and acetabular rim can be accessed

46. TOTAL HIP ARTHROPLASTY 

47. references Campbell’s OPERATIVE ORTHOPAEDICS Tachdjian’s Pediatric Orthopaedics Frederic Shapiro Pediatric Orthopedic Deformities Pietro Randelli (ESSKA) Arthroscopy Basic to Advanced