Femoroacetabular Impingement (FAI)

Femoroacetabular Impingement (FAI) is a condition in which the femoral head and neck area or the acetabulum have a shape that do not allow it to fully move without colliding.

There are three types, Cam, Pincer, and Mixed

1. Cam type is described as a bony bump on the femoral neck next to the head. This bump collides with the acetabular labrum and often tears it by pushing it off the rim of the acetabulum. This results in pain. Some small partial tears can heal but chronic partial, and full thickness tears often do not heal due to the repetitive collisions of the femoral head neck onto the injured labrum everytime the hip is flexed up past 90 degrees. As the labrum becomes injured then the acetabular cartilage will become injured as it is no longer protected by the labrum. This can progress over an extended period of time into hip osteoarthritis.
2. Pincer type impingement is due to a deeper socket or backward facing socket. The front edge (anterior) will collide with the neck causing a crushing type injury to the labrum causing pain. The cartilage is usually protected except in some cases the femoral head is levered out of the socket against the posterior cartilage causing damage there.
3. Mixed type is a combination of both Cam and Pincer type impingements and can produce mixed type injuries to the bone, cartilage and labrum.

Symptoms:

Symptoms of femoroacetabular impingement can include the following:

• Groin pain associated with hip activity
• Complaints of pain in the front, side or back of the hip
• Pain may be described as a dull ache or sharp pain
• Patients may complain of a locking, clicking, or catching sensation in the hip
• Pain often occurs to the inner hip or groin area after prolonged sitting or walking
• Difficulty walking uphill
• Restricted hip movement
• Low back pain
• Pain in the buttocks or outer thigh area

Risk Factors:

Risk factors for developing femoroacetabular impingement may include the following:

• Athletes such as football players, weight lifters, and hockey players
• Heavy laborers
• Repetitive hip flexion
• Congenital hip dislocation
• Anatomical abnormalities of the femoral head or angle of the hip
• Legg-Calves-Perthes disease: a form of arthritis in children where blood supply to bone is impaired causing bone breakdown.
• Trauma to the hip Inflammatory arthritis

Diagnosis:

Hip conditions should be evaluated by a specialized hip surgeon, such as Dr. Faucett, for proper diagnosis and treatment. Diagnosis includes the following evaluations:

1. Medical History
2. Physical Examination
3. Diagnostic Studies may include:
   1. Xray A form of electromagnetic radiation that is used to take pictures of bones. X-rays will show Dr. Faucett the shape of the ball and socket as well as the amount of joint space present.
   2. MRI Magnetic and radio waves are used to create a computer image of soft tissue such as nerves and ligaments. An MRI assists Dr. Faucett in ruling out other causes of hip pain. The MRI may be ordered with contrast dye to provide more information to Dr. Faucett.
   3. CT Scan This test creates 3D images from multiple x-rays and shows your physician hip structures not seen on regular x-ray.

Conservative Treatment Options:

Conservative treatment options refer to management of the problem without surgery. Nonsurgical management of FAI will probably not change the underlying abnormal biomechanics of the hip causing the FAI but may offer pain reh2ef and improved mobility. Some conservative treatment measures include:

• Rest Activity Modification and Limitations
• Anti-inflammatory Medications
• Physical Therapy
• Injection of steroid and analgesic into the hip joint

Surgical Treatment:

Hip Arthroscopy to repair femoroacetabular impingement is indicated when conservative treatment measures fail to provide relief to the patient.

Hip Arthroscopy is a surgical procedure in which an arthroscope is inserted into the hip joint to assess and repair damage to the hip. Hip Arthroscopy is performed in a hospital operating room under general or regional anesthesia depending on you and Dr. Faucett’s preference. This surgery is usually performed as day surgery or outpatient surgery, enabling the patient to go home the same day. The arthroscope used in Hip Arthroscopy is a small fiber-optic viewing instrument made up of a tiny lens, light source and video camera. The surgical instruments used in arthroscopic surgery are very small (only 3 or 4 mm in diameter), but appear much larger when viewed through an arthroscope. The television camera attached to the arthroscope displays the image of the joint on a television screen, allowing the surgeon to look throughout the hip joint. The surgeon can then determine the amount or type of injury, and then repair or correct the problem as necessary. In arthroscopic repair of FAI, Dr. Faucett may perform the following procedures:

• Labrum Repair: This refers to surgery to repair the torn labrum. Sutures are used to reattach the torn labrum.
• Microfracture: This involves drilling holes into exposed bone where cartilage is missing to promote the formation of new cartilage
• Chondroplasty: This type of debridement refers to cutting out and removing pieces of torn or frayed labrum or cartilage.
• FAI decompression: This involves removing any excess of bone in certain areas around the femoral head and neck (ball) areas, such as bony bumps, causing the impingement.
• Osteoplasty: This refers to a surgical procedure to modify or alter the shape of a bone.

The benefits of arthroscopic repair of FAI versus open treatment (surgical hip dislocation), include:

• Smaller incisions
• Minimal soft tissue trauma
• Less pain
• Faster healing time
• Lower infection rate
• Less scarring
• Earlier mobilization
• Usually performed as outpatient day surgery

Arthroscopic Surgical Procedure:

Dr. Faucett will make two or three small incisions, about 1/4 of an inch each, around the hip joint area. Each incision is called a portal. These incisions result in very small scars which in many cases are unnoticeable.

A blunt tube, called a Trocar, is inserted into each portal prior to the insertion of the arthroscope and surgical instruments. In one portal, the arthroscope is inserted to view the hip joint. Along with the arthroscope, a sterile salt water (saline) solution is pumped into the joint to expand the viewing area, giving the surgeon a clear view and room to work.

With the images from the arthroscope as a guide, the surgeon can look for any injury or anomaly. The large image on the television screen allows the surgeon to see the joint directly and to determine the extent of the injuries and then to perform the surgical procedure as needed.

The other portals are used for the insertion of surgical instruments to probe various parts within the joint to determine the extent of the problem. If the surgeon sees an opportunity to treat a problem, a variety of surgical instruments can be inserted through this portal.

For FAI surgery, Dr Faucett, will use a special instrument called a coblation wand to remove or debride any frayed cartilage. If the labrum is torn, Dr. Faucett will use sutures to preserve and reattach the labrum.

Any bony bumps present contributing to the impingement will also be burred away and smoothed.

If there is any deep or extensive cartilage damage, Dr. Faucett will drill holes in bone that has no cartilage covering it. This technique is called microfracture and stimulates the formation of new cartilage.

Once Dr. Faucett is satisfied with the results the instruments and arthroscope are removed from the portals. The portals (incisions) are then closed by suturing or by tape.

Post Operative Care:

After surgery Dr. Faucett will give you guidelines to follow depending on the type of repair performed and the surgeon’s preference.

Common Post-operative guidelines include:

• Dr. Faucett will prescribe pain medications to keep you comfortable at home.
• Keep the incisions clean and dry. You may shower once the dressings are removed unless otherwise directed by Dr. Faucett’s team.
• You will have crutches for the first 2 weeks after surgery to limit weight bearing on the hip.
• You will be given specific instructions regarding activity and rehabilitation.
• Physical therapy will be ordered to restore normal hip function, flexibility and strength.

It is important to keep all your post operative appointments with Dr. Faucett to ensure a good outcome. Eating a healthy diet and not smoking will promote healing.

Risks and Complications:

As with any major surgery there are potential risks involved. The decision to proceed with the surgery is made because the advantages of surgery outweigh the potential disadvantages. It is important that you are informed of these risks before the surgery takes place. Complications can be medical (general) or specific to Hip Arthroscopy surgery.

Medical complications include those of the anesthetic and your general well being. Almost any medical condition can occur so this list is not complete.

Complications include:

• Allergic reactions to medications
• Blood loss requiring transfusion with its low risk of disease transmission
• Heart attacks, strokes, kidney failure, pneumonia, bladder infections
• Complications from nerve blocks such as infection or nerve damage
• Serious medical problems can lead to ongoing health concerns, prolonged hospitalization, or rarely death.

Complications are rare after hip arthroscopy surgery, but unexpected events can follow any operation. Dr. Faucett feels that you should be aware of complications that may take place so that your decision to proceed with this operation is taken with all relevant information available to you. Specific complications that can occur following hip arthroscopy include:

• Infection
• Nerve Damage
• Hemarthrosis
• Blood Clots
• Avascular Necrosis
• Failure to Relieve Pain
• Infection – Infections can occur superficially at the portal insertion sites or in the joint space of the hip, a more serious infection.
• Nerve Damage – Trauma to nerves may be temporary or permanent and can cause numbness, tingling, pain, and weakness. The nerves most at risk for damage include lateral femoral cutaneous from portal insertion and pudendal and sciatic nerve from traction. Dr. Faucett does not use a post during hip arthroscopy which will limit the risks of groin numbness compared to techniques that use a post.
• Hemarthrosis – A condition caused by excess bleeding into the joint after the surgery is completed. This may require additional arthroscopic surgery to irrigate the joint and evacuate the blood.
• Blood Clots – These can form in the calf muscles and can travel to the lung (Pulmonary embolism). These can occasionally be serious and even life threatening. If you get calf pain or shortness of breath at any stage, you should notify Dr. Faucett.
• Avascular Necrosis – AVN of the femoral head causes bone death due to lack of blood supply to the bone.
• Failure to Relieve Pain – This is rare but may occur especially if some pain is coming from other areas such as the spine.

Risk factors that can negatively affect adequate healing after surgery include:

• Chronic Illness
• Steroid Use
• Poor nutrition
• Smoking
• Alcoholism
• Narcotic drug overuse