SpringerLink
Log in

Femoroacetabular Im**ement (FAI): Current Clinical Approaches

  • Sports Medicine Rehabilitation (BC Liem and JA Soo Hoo, Section Editors)
  • Published:
Current Physical Medicine and Rehabilitation Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

The purpose of this paper is to review the history of femoroacetabular im**ement (FAI), discuss its pathophysiology and clinical presentation, identify radiographic parameters used to characterize FAI, and provide an updated summary of outcome-based non-operative and surgical treatments for FAI syndrome based on recent trends and developments.

Recent Findings

Recent literature has shed further light onto the detailed pathophysiologic mechanisms of FAI syndrome, particularly in its relation to both osteoarthritis and hip dysplasia. This and recent outcome data have led to the development of improved diagnostic and treatment algorithms that incorporate specific radiologic studies and parameters, allowing for better patient selection for non-operative and operative treatment strategies.

Summary

Along with a detailed history and physical examination, specific radiographic parameters allow for more precise identification FAI. These include, but are not limited to, the alpha angle, head-neck offset (HNO), lateral center edge angle (CEA), femoral version, and acetabular version. The clinician should also evaluate for concomitant cartilage degradation, labral pathology, and the presence of dysplastic features or instability, which have been shown to significantly affect treatment outcomes. This is reflected in recent best practice guidelines.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Otto AW. Seltene Beobachtungen zur Anatomie. Holäufer: Physiologie und Pathologie gehörig; 1816.

    Google Scholar 

  2. Poland J. Traumatic separation of the epiphyses in general. Clinical Orthopaedics and Related Research (1976-2007). 1965;41:7.

    Article  Google Scholar 

  3. Myers SR, Eijer H, Ganz R. Anterior femoroacetabular im**ement after periacetabular osteotomy. Clin Orthop Relat Res. 1999:93–9.

  4. Ganz R, Gill TJ, Gautier E, Ganz K, Krügel N, Berlemann U. Surgical dislocation of the adult hip a technique with full access to the femoral head and acetabulum without the risk of avascular necrosis. J Bone Joint Surg Br. 2001;83:1119–24.

    Article  CAS  PubMed  Google Scholar 

  5. Griffin D, Dickenson E, O’Donnell J, Agricola R, Awan T, Beck M, et al. The Warwick Agreement on femoroacetabular im**ement syndrome (FAI syndrome): an international consensus statement | British Journal of Sports Medicine. British journal of sports medicine. 2016;50:1169–76.

    Article  CAS  PubMed  Google Scholar 

  6. Hack K, Di Primio G, Rakhra K, Beaulé PE. Prevalence of cam-type femoroacetabular im**ement morphology in asymptomatic volunteers. J Bone Joint Surg Am. 2010;92:2436–44.

    Article  PubMed  Google Scholar 

  7. Gosvig KK, Jacobsen S, Sonne-Holm S, Gebuhr P. The prevalence of cam-type deformity of the hip joint: a survey of 4151 subjects of the Copenhagen Osteoarthritis Study. Acta Radiol. 2008;49:436–41.

    Article  CAS  PubMed  Google Scholar 

  8. Frank JM, Harris JD, Erickson BJ, Slikker W, Bush-Joseph CA, Salata MJ, et al. Prevalence of femoroacetabular im**ement imaging findings in asymptomatic volunteers: a systematic review. Arthroscopy. 2015;31:1199–204.

    Article  PubMed  Google Scholar 

  9. Ganz R, Parvizi J, Beck M, Leunig M, Nötzli H, Siebenrock K. Femoroacetabular im**ement: a cause for osteoarthritis of the hip. Clinical Orthopaedics and Related Research. 2003;417:112–20.

    Google Scholar 

  10. Beck M, Kalhor M, Leunig M, Ganz R. Hip morphology influences the pattern of damage to the acetabular cartilage: femoroacetabular im**ement as a cause of early osteoarthritis of the hip. J Bone Joint Surg Br. 2005;87:1012–8.

    Article  CAS  PubMed  Google Scholar 

  11. Tibor L, Leunig M. The pathoanatomy and arthroscopic management of femoroacetabular im**ement. Bone Joint Res. 2012;1:245–57.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Leunig M, Beaulé PE, Ganz R. The concept of femoroacetabular im**ement: current status and future perspectives. Clin Orthop Relat Res. 2009;467:616–22.

    Article  PubMed  Google Scholar 

  13. Siebenrock KA, Ferner F, Noble PC, Santore RF, Werlen S, Mamisch TC. The cam-type deformity of the proximal femur arises in childhood in response to vigorous sporting activity. Clin Orthop Relat Res. 2011;469:3229–40.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Parvizi J, Leunig M, Ganz R. Femoroacetabular im**ement. J Am Acad Orthop Surg. 2007;15:561–70.

    Article  PubMed  Google Scholar 

  15. Anderson LA, Kapron AL, Aoki SK, Peters CL. Coxa profunda: is the deep acetabulum overcovered? Clin Orthop Relat Res. 2012;470:3375–82.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Bedi A, Dolan M, Leunig M, Kelly BT. Static and dynamic mechanical causes of hip pain. Arthroscopy. 2011;27:235–51.

    Article  PubMed  Google Scholar 

  17. Poultsides LA, Bedi A, Kelly BT. An algorithmic approach to mechanical hip pain. HSS J. 2012;8:213–24.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Offierski C, MacNab I. Hip-spine syndrome. Spine. 1983;8:316–21.

    Article  CAS  PubMed  Google Scholar 

  19. Ben-Galim P, Ben-Galim T, Rand N, Haim A, Hipp J, Dekel S, et al. Hip-spine syndrome: the effect of total hip replacement surgery on low back pain in severe osteoarthritis of the hip. Spine (Phila Pa 1976). 2007;32:2099–102.

    Article  Google Scholar 

  20. Kim D-H, Park J-K, Jeong M-K. Influences of posterior-located center of gravity on lumbar extension strength, balance, and lumbar lordosis in chronic low back pain. J Back Musculoskelet Rehabil. 2014;27:231–7.

    Article  PubMed  Google Scholar 

  21. Ross JR, Nepple JJ, Philippon MJ, Kelly BT, Larson CM, Bedi A. Effect of changes in pelvic tilt on range of motion to im**ement and radiographic parameters of acetabular morphologic characteristics. Am J Sports Med. 2014;42:2402–9.

    Article  PubMed  Google Scholar 

  22. Luo R, Barsoum D, Ashraf H, Cheng J, Hurwitz N, Goldsmith C, et al. Prevalence of lumbosacral transitional vertebrae in patients with symptomatic femoroacetabular im**ement requiring hip arthroscopy. Arthroscopy: The Journal of Arthroscopic & Related Surgery. W.B. Saunders; 2020 [cited 2020 Sep 10]; Available from: https://www.sciencedirect.com/science/article/abs/pii/S0749806320307295.

  23. Gebhart JJ, Streit JJ, Bedi A, Bush-Joseph CA, Nho SJ, Salata MJ. Correlation of pelvic incidence with cam and pincer lesions. Am J Sports Med. 2014;42:2649–53.

    Article  PubMed  Google Scholar 

  24. Hellman MD, Haughom BD, Brown NM, Fillingham YA, Philippon MJ, Nho SJ. Femoroacetabular im**ement and pelvic incidence: radiographic comparison to an asymptomatic control. Arthroscopy. 2017;33:545–50.

    Article  PubMed  Google Scholar 

  25. Ng KCG, Lamontagne M, Jeffers JRT, Grammatopoulos G, Beaulé PE. Anatomic predictors of sagittal hip and pelvic motions in patients with a cam deformity. Am J Sports Med. 2018;46:1331–42.

    Article  PubMed  Google Scholar 

  26. Bertolotti M. Contributo alla conoscenze dei vizi di differenzazione regionale del racide con speciale riguardo alla assimilazione sacrale della V. lombare. Radiologique Medica. 1917;4:113–44.

    Google Scholar 

  27. Vergauwen S, Parizel PM, van Breusegem L, Van Goethem JW, Nackaerts Y, Van den Hauwe L, et al. Distribution and incidence of degenerative spine changes in patients with a lumbo-sacral transitional vertebra. Eur Spine J. 1997;6:168–72.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  28. Clohisy JC, Knaus ER, Hunt DM, Lesher JM, Harris-Hayes M, Prather H. Clinical presentation of patients with symptomatic anterior hip im**ement. Clin Orthop Relat Res. 2009;467:638–44.

    Article  PubMed  PubMed Central  Google Scholar 

  29. Nawabi DH, Bedi A, Tibor LM, Magennis E, Kelly BT. The demographic characteristics of high-level and recreational athletes undergoing hip arthroscopy for femoroacetabular im**ement: a sports-specific analysis. Arthroscopy. 2014;30:398–405.

    Article  PubMed  Google Scholar 

  30. Tijssen M, van Cingel R, Willemsen L, de Visser E. Diagnostics of femoroacetabular im**ement and labral pathology of the hip: a systematic review of the accuracy and validity of physical tests. Arthroscopy. 2012;28:860–71.

    Article  PubMed  Google Scholar 

  31. Reiman MP, Goode AP, Cook CE, Hölmich P, Thorborg K. Diagnostic accuracy of clinical tests for the diagnosis of hip femoroacetabular im**ement/labral tear: a systematic review with meta-analysis. Br J Sports Med; 2015 [cited 2021 Apr 5];49. Available from: https://pubmed.ncbi.nlm.nih.gov/25515771/.

  32. Freke MD, Kemp J, Svege I, Risberg MA, Semciw A, Crossley KM. Physical impairments in symptomatic femoroacetabular im**ement: a systematic review of the evidence. Br J Sports Med. 2016;50:1180.

    Article  PubMed  Google Scholar 

  33. Braly BA, Beall DP, Martin HD. Clinical examination of the athletic hip. Clin Sports Med. 2006;25:199–210 vii.

    Article  PubMed  Google Scholar 

  34. Nepple JJ, Prather H, Trousdale RT, Clohisy JC, Beaulé PE, Glyn-Jones S, et al. Diagnostic imaging of femoroacetabular im**ement. JAAOS - J Am Acad Orthop Surg. 2013;21:S20.

    PubMed  Google Scholar 

  35. Beck M, Leunig M, Parvizi J, Boutier V, Wyss D, Ganz R. Anterior femoroacetabular im**ement: part II. Midterm results of surgical treatment. Clin Orthop Relat Res. 2004;418:67–73.

    Article  Google Scholar 

  36. Fuchs-Winkelmann S, Peterlein C-D, Tibesku CO, Weinstein SL. Comparison of pelvic radiographs in weightbearing and supine positions. Clin Orthop Relat Res. 2008;466:809–12.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Auleley G, Rousselin B, Ayral X, Edouard-Noel R, Dougados M, Ravaud P. Osteoarthritis of the hip: agreement between joint space width measurements on standing and supine conventional radiographs. Ann Rheum Dis. 1998;57:519–23.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  38. Clohisy JC, Carlisle JC, Beaule PE, Kim Y-J, Trousdale R, Sierra R, et al. A systematic approach to the plain radiographic evaluation of the young adult hip. J Bone Joint Surg Am. 2008;90:47–66.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Nepple JJ, Martel JM, Kim Y-J, Zaltz I, Clohisy JC. Do plain radiographs correlate with CT for imaging of cam-type femoroacetabular im**ement? Clin Orthop Relat Res. 2012;470:3313–20.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Meyer D, Beck M, Ellis T, Ganz R, Leunig M. Comparison of six radiographic projections to assess femoral head/neck asphericity. - PubMed - NCBI. Clin Orthop Related Research. 2006;445:181–5.

    Article  Google Scholar 

  41. Pollard TCB, Villar RN, Norton MR, Fern ED, Williams MR, Simpson DJ, et al. Femoroacetabular im**ement and classification of the cam deformity: the reference interval in normal hips. Acta Orthop. 2010;81:134–41.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Mascarenhas VV, Castro MO, Rego PA, Sutter R, Sconfienza LM, Kassarjian A, et al. The Lisbon Agreement on femoroacetabular im**ement imaging-part 1: overview. Eur Radiol. 2020;30:5281–97.

    Article  PubMed  Google Scholar 

  43. Eijer H, Leunig M, Mahomed MN, Ganz R. Cross-table lateral radiographs for screening of anterior femoral head-neck offset in patients with femoro-acetabular im**ement. HIP International SAGE Publications. 2001;11:37–41.

    Article  Google Scholar 

  44. Leunig M, Beck M, Kalhor M, Kim Y-J, Werlen S, Ganz R. Fibrocystic changes at anterosuperior femoral neck: prevalence in hips with femoroacetabular im**ement. Radiology. 2005;236:237–46.

    Article  PubMed  Google Scholar 

  45. Daenen B, Preidler KW, Padmanabhan S, Brossmann J, Tyson R, Goodwin DW, et al. Symptomatic herniation pits of the femoral neck: anatomic and clinical study. AJR Am J Roentgenol. 1997;168:149–53.

    Article  CAS  PubMed  Google Scholar 

  46. Kalberer F, Sierra RJ, Madan SS, Ganz R, Leunig M. Ischial spine projection into the pelvis: a new sign for acetabular retroversion. Clin Orthop Relat Res. 2008;466:677–83.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Siebenrock KA, Kalbermatten DF, Ganz R. Effect of pelvic tilt on acetabular retroversion: a study of pelves from cadavers. Clin Orthop Relat Res. 2003;407:241–8.

    Article  Google Scholar 

  48. Zaltz I, Kelly BT, Hetsroni I, Bedi A. The crossover sign overestimates acetabular retroversion. Clin Orthop Relat Res. 2013;471:2463–70.

    Article  PubMed  Google Scholar 

  49. Leunig M, Nho SJ, Turchetto L, Ganz R. Protrusio acetabuli: new insights and experience with joint preservation. Clin Orthop Relat Res. 2009;467:2241–50.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Tannast M, Siebenrock KA, Anderson SE. Femoroacetabular im**ement: radiographic diagnosis—what the radiologist should know. American Journal of Roentgenology. American Roentgen Ray Society. 2007;188:1540–52.

    Article  Google Scholar 

  51. Tannast M, Hanke MS, Zheng G, Steppacher SD, Siebenrock KA. What are the radiographic reference values for acetabular under- and overcoverage? Clin Orthop Relat Res. 2015;473:1234–46.

    Article  PubMed  Google Scholar 

  52. Lee CB, Kim Y-J. Imaging hip dysplasia in the skeletally mature. Orthop Clin North Am. 2012;43:329–42.

    Article  PubMed  Google Scholar 

  53. Wells J, Nepple JJ, Crook K, Ross JR, Bedi A, Schoenecker P, et al. Femoral morphology in the dysplastic hip: three-dimensional characterizations with CT. Clin Orthop Relat Res. 2017;475:1045–54.

    Article  PubMed  Google Scholar 

  54. Mintz D, Hooper T, Connell D, Buly R, Padgett D, Potter H. Magnetic resonance imaging of the hip: detection of labral and chondral abnormalities using noncontrast imaging. Arthroscopy. 2005;21:385–93.

    Article  PubMed  Google Scholar 

  55. Menge TJ, Briggs KK, Dornan GJ, McNamara SC, Philippon MJ. Survivorship and outcomes 10 years following hip arthroscopy for femoroacetabular im**ement: labral debridement compared with labral repair. J Bone Joint Surg Am. 2017;99:997–1004.

    Article  PubMed  Google Scholar 

  56. Ross JR, Larson CM, Adeoyo O, Kelly BT, Bedi A. Residual deformity is the most common reason for revision hip arthroscopy: a three-dimensional CT study. Clin Orthop Relat Res. 2015;473:1388–95.

    Article  PubMed  Google Scholar 

  57. Kivlan BR, Martin RL, Sekiya JK. Response to diagnostic injection in patients with femoroacetabular im**ement, labral tears, chondral lesions, and extra-articular pathology. Arthroscopy. 2011;27:619–27.

    Article  PubMed  Google Scholar 

  58. Khan W, Khan M, Alradwan H, Williams R, Simunovic N, Ayeni OR. Utility of intra-articular hip injections for femoroacetabular im**ement: a systematic review. Orthop J Sports Med. 2015;3:2325967115601030.

    Article  PubMed  PubMed Central  Google Scholar 

  59. Gao G, Fu Q, Wu R, Liu R, Cui L, Xu Y. Ultrasound and ultrasound-guided hip injection have high accuracy in the diagnosis of femoroacetabular im**ement with atypical symptoms. Arthroscopy. 2021;37:128–35.

    Article  PubMed  Google Scholar 

  60. Wall PDH, Fernandez M, Griffin DR, Foster NE. Nonoperative treatment for femoroacetabular im**ement: a systematic review of the literature. PM R. 2013;5:418–26.

    Article  PubMed  Google Scholar 

  61. Wright AA, Tarara DT, Gisselman AS, Dischiavi SL. Do currently prescribed exercises reflect contributing pathomechanics associated with femoroacetabular im**ement syndrome? A sco** review. Phys Ther Sport. 2021;47:127–33.

    Article  PubMed  Google Scholar 

  62. • Minkara AA, Westermann RW, Rosneck J, Lynch TS. Systematic review and meta-analysis of outcomes after hip arthroscopy in femoroacetabular im**ement. Am J Sports Med. 2019;47:488–500. There is limited aggregate published data on surgical outcomes following arthroscopic management of FAI. This study presents a systematic review and meta-analysis on the patient reported outcomes following arthroscopy, specifically reporting a high return to sport rate in addition to low complication rates and surgical revisions.

    Article  PubMed  Google Scholar 

  63. Botser IB, Smith TW, Nasser R, Domb BG. Open surgical dislocation versus arthroscopy for femoroacetabular im**ement: a comparison of clinical outcomes. Arthroscopy. 2011;27:270–8.

    Article  PubMed  Google Scholar 

  64. •• Lynch TS, Minkara A, Aoki S, Bedi A, Bharam S, Clohisy J, et al. Best practice guidelines for hip arthroscopy in femoroacetabular im**ement: results of a Delphi process. J Am Acad Orthop Surg. 2020;28:81–9. This is the first study to report on the best practice guidelines among a group of hip arthroscopy experts, suggesting guidelines for preoperative management, intraoperative practices, and post-operative protocols. These guidelines are critical for influencing current future care practices for patients presenting with FAI.

    Article  PubMed  Google Scholar 

  65. Philippon MJ, Briggs K, Yen Y-M, Kuppersmith DA. Outcomes following hip arthroscopy for femoroacetabular im**ement with associated chondrolabral dysfunction: minimum two-year follow-up | Ovid. Journal of Bone and Joint Surgery Br. 2009;91:16–23.

    Article  CAS  Google Scholar 

  66. Zimmerer A, Schneider MM, Nietschke R, Miehlke W, Sobau C. Is hip arthroscopy an adequate therapy for the borderline dysplastic hip? Correlation between radiologic findings and clinical outcomes. Orthop J Sports Med. 2020;8:2325967120920851.

    Article  PubMed  PubMed Central  Google Scholar 

  67. McQuivey KS, Secretov E, Domb BG, Levy BA, Krych AJ, Neville M, et al. A multicenter study of radiographic measures predicting failure of arthroscopy in borderline hip dysplasia: beware of the Tönnis angle. Am J Sports Med. 2020;48:1608–15.

    Article  PubMed  Google Scholar 

  68. • Ross JR, Clohisy JC, Bedi A, Zaltz I. Why does hip arthroscopy fail? Indications and PEARLS for revision success. Sports Med Arthrosc Rev. 2021;4:44–51. While surgical interventions for the treatment of FAI have been shown to improve patient outcomes, this study focuses on the cohort of patients that report unchanged or worsened outcomes following surgical intervention. This study suggests evaluating revision patients with a specific focus on hip anatomy and morphology, targeting the source of failure to determine the best course of treatment.

    Article  Google Scholar 

  69. Esposito CI, Miller TT, Kim HJ, Barlow BT, Wright TM, Padgett DE, et al. Does degenerative lumbar spine disease influence femoroacetabular flexion in patients undergoing total hip arthroplasty? Clin Orthop Relat Res. 2016;474:1788–97.

    Article  PubMed  PubMed Central  Google Scholar 

  70. May O, Ouattara K, Flecher X, Wettstein M. Francophone Arthroscopy Society (SFA). Does labral repair have a clinical benefit during arthroscopic treatment of femoro-acetabular im**ement? Prospective multicentre study with 2-year follow-up. Orthop Traumatol Surg Res. 2020;106:S237–41.

    Article  PubMed  Google Scholar 

  71. •• Suppauksorn S, Beck EC, Chahla J, Cancienne JM, Krivicich LM, Rasio J, et al. Comparison of suction seal and contact pressures between 270° labral reconstruction, labral repair, and the intact labrum. Arthroscopy. 2020;36:2433–42. This study evaluated the suction seal, contact area, contact pressures, and peak forces of a normal labrum, torn labrum, a labral repair, and labral reconstruction. The results demonstrated that a labral reconstruction resulted in a lower intra-articular hip contact area and loss of suction seal in comparison to a labral repair, further implicating the clinical efficacy of a labral reconstruction versus a labral repair.

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Physical Medicine and Rehabilitation, Hospital for Special Surgery, 541 E 71st St 1st Floor, New York, NY, 10021, USA

    Roderick Geer, Campbell Goldsmith & Peter J. Moley

Authors
  1. Roderick Geer
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Campbell Goldsmith
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Peter J. Moley
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Peter J. Moley.

Ethics declarations

Conflict of Interest

None of the authors have any potential conflicts of interest to disclose.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

This article is part of the Topical Collection on Sports Medicine Rehabilitation

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Geer, R., Goldsmith, C. & Moley, P.J. Femoroacetabular Im**ement (FAI): Current Clinical Approaches. Curr Phys Med Rehabil Rep 9, 70–78 (2021). https://doi.org/10.1007/s40141-021-00309-4

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s40141-021-00309-4

Keywords

Search

Navigation