Hip Impingement (FAI) Arthroscopic Repair

What Is Hip Impingement (Femoroacetabular Impingement – FAI)?

Femoroacetabular Impingement (FAI) is a mechanical problem caused by abnormal contact between the ball (femur) and socket (acetabulum) components of the hip joint. Normally, during hip joint movements, these two structures move in harmony without striking each other. In FAI, however, due to shape abnormalities in the bony structures, this harmony is disrupted — particularly during movements where the hip is flexed and internally rotated — and the bones rub or strike against each other or against the labrum in between. There are two main types of FAI, and they frequently occur together (Mixed Type):

1. CAM-Type Impingement: The problem is on the femur side. Instead of the slight concavity that should normally exist at the transition zone between the femoral head and neck, there is a non-spherical abnormal bony prominence (bump). When the hip is flexed, this bump-shaped prominence strikes against the rim of the acetabular socket, first tearing the labrum and then stripping the cartilage. It is generally more common in young, active men.
2. PINCER-Type Impingement: The problem is on the acetabulum (socket) side. The rim of the socket overcovers the femoral head (a deep socket or a bony prominence at the rim), or the angle of the socket is abnormal (retroversion). Even if the femoral neck is normal during hip movement, the excessive bony rim of the socket compresses the labrum and damages it over time. It is generally more common in middle-aged women.

This repeated abnormal contact and impingement leads to progressive damage in the hip joint: first the labrum tears, then the adjacent cartilage is damaged, and if the process continues, widespread joint osteoarthritis develops.

The Goal of FAI Surgery: The primary goal of arthroscopic FAI surgery is to break this vicious cycle:

• Restoring normal joint mechanics by shaving down the abnormal bony prominences (Cam and/or Pincer lesions) causing the impingement.
• Repairing the labrum that has been damaged due to the impingement.
• Treating any accompanying cartilage damage.
• Relieving pain and eliminating mechanical symptoms such as catching.
• Improving hip function and range of motion.
• In the long term, preventing or delaying the development of hip osteoarthritis.

Why Does FAI Occur? Risk Factors

FAI is generally a structural condition that arises during the growth and development of the bones, meaning it does not develop later in life. However, its symptoms usually appear in young adulthood or middle age. Although the exact causes are not fully known, the following factors may play a role:

• Developmental Factors: The femoral head/neck or acetabulum forming differently than normal as the bones’ growth plates close.
• Intense Physical Activity (During Adolescence): Sports that frequently stress the hip (such as soccer, ice hockey, basketball, and ballet), especially when practiced during the growth years, can affect bone shaping and set the stage for the development of FAI.
• Childhood Hip Diseases: Mild-grade Slipped Capital Femoral Epiphysis (SCFE) or sequelae of Perthes disease.
• Genetic Predisposition: A familial predisposition is thought to be possible.

What Are the Symptoms of FAI?

FAI symptoms usually begin insidiously and increase over time. The most common symptom is groin pain.

• Pain: Usually felt in the groin or the front of the hip. It can sometimes radiate to the side or back of the hip (buttock area). The pain is often a dull, aching pain that increases with activity, but it can also be a sharp, stabbing pain that occurs with certain movements (deep squatting, getting in and out of a car, internally rotating the hip). Prolonged sitting can also increase the pain.
• Mechanical Symptoms: A sensation of clicking, popping, catching, or locking in the hip during movement. These symptoms usually indicate an accompanying labral tear.
• Restricted Motion: Restriction and pain, especially with hip flexion and internal rotation. Difficulty sitting cross-legged or putting on socks.
• Decreased Performance: Decreased performance in athletes, difficulty with movements.

How Is Hip Impingement (FAI) Diagnosed?

FAI is diagnosed through a detailed history, careful physical examination, and specialized imaging methods:

• Detailed History: The location, onset, and character of the pain, which movements increase it, mechanical symptoms, and sports practiced are questioned.
• Physical Examination: Hip range of motion (especially restriction in flexion and internal rotation) is measured. Special impingement tests such as the FADIR test (reproduction of groin pain with flexion, adduction, and internal rotation of the hip) are performed. A positive result on this test strengthens the suspicion of FAI.
• Imaging Methods:
  
  • X-ray: This is the fundamental method for diagnosing FAI and determining its type. An AP pelvis view and special hip radiographs (such as frog-leg lateral, Dunn 45°/90°, and cross-table lateral) are taken to examine bone morphology in detail. The size of the Cam lesion (alpha angle measurement), the presence of a Pincer lesion (acetabular coverage, retroversion), and the joint space (osteoarthritis?) are assessed.
  • Computed Tomography (CT) / 3D CT: Used especially to visualize the bony structure more clearly in three dimensions and for surgical planning.
  • Magnetic Resonance (MR) Imaging or MR Arthrography (MRA): The most valuable method for demonstrating the soft tissue damage (labral tear, cartilage damage) caused by FAI. MRA (contrast-enhanced MRI) shows labral tears more precisely.

Treatment Options: Conservative or Surgical?

• Non-surgical (Conservative) Treatment: This can be tried initially to relieve symptoms. It includes activity modification (avoiding movements that cause impingement), NSAIDs, physical therapy (strengthening the core and hip muscles, flexibility, while avoiding movements that would increase impingement), and intra-articular injections (cortisone or hyaluronic acid — for temporary relief). However, conservative treatment does not correct the underlying bony problem and generally does not provide a permanent solution. Symptoms frequently persist or recur.
• Surgical Treatment: Arthroscopic FAI Surgery: This is the gold-standard treatment method for patients who do not respond to conservative treatment, whose daily life or sports activities are restricted, whose imaging shows FAI with associated labral/cartilage damage, and who do not yet have advanced osteoarthritis.

Arthroscopic FAI Surgery: A Comprehensive Treatment Approach

Hip arthroscopy allows the hip joint to be treated using a minimally invasive (closed) method. The goal is to correct the bony structures causing the impingement and to repair the resulting soft tissue damage:

1. Intra-articular Assessment: The arthroscope is inserted into the joint, and all structures — the labrum, cartilage surfaces (femoral head and acetabulum), and the ligamentum teres — are examined in detail and any damage is identified.
2. Labral Repair (or Debridement): If the tissue quality is adequate, the torn labrum is resutured to the bony rim using suture anchors (repair). If it is too worn to be repaired, it is cleaned up (debridement). The goal is to preserve labral function as much as possible.
3. Correcting the Bony Impingement (Osteoplasty): This is the most critical part of the surgery.
   
   • Acetabular Rim Trimming (for Pincer Lesions): The excess bony prominence at the rim of the socket is carefully shaved down with an arthroscopic burr.
   • Femoral Osteochondroplasty (for Cam Lesions): The abnormal bony prominence at the femoral head/neck junction is likewise carefully shaved down with the arthroscopic burr and restored to its normal anatomical shape. During surgery, the hip is moved to confirm that the impingement has been resolved.
4. Cartilage Treatment: If there is significant cartilage damage, additional cartilage procedures such as debridement or microfracture may also be performed in the same session.

The secret to success is treating both the soft tissue damage, such as to the labrum, and the underlying bony problems, such as FAI, simultaneously and completely. Prof. Dr. Murat Bozkurt performs this comprehensive arthroscopic FAI surgery in Ankara.

Risks, Benefits, and the Demanding Recovery Process

• Benefits: Relief of pain (especially groin pain) and mechanical symptoms (catching, locking), increased hip range of motion and function, the ability to return to sports and an active lifestyle, and a potential reduction or delay in the risk of hip osteoarthritis.
• Risks: General surgical risks (infection, DVT/PE, anesthesia). Risks specific to hip arthroscopy (temporary or, rarely, permanent nerve damage, traction-related complications, joint stiffness, heterotopic ossification). Risks related to the procedure performed (failure of the labral repair, insufficient or excessive bone shaving — which can rarely lead to instability, persistent pain).
• Recovery Process: Recovery after hip FAI surgery is a long process that requires patience and discipline.
  
  • Crutches: Protected weight-bearing with crutches is generally required for 4-6 weeks to protect the labral repair and bone healing.
  • Movement Restrictions: Certain hip movements are restricted initially.
  • Physical Therapy: Absolutely necessary and lasts for months. Specialized hip arthroscopy rehabilitation protocols are applied. Range of motion, muscle strength, balance, and function are regained slowly and progressively.
  • Return to Sports: This generally takes between 6 and 12 months and requires physician/physiotherapist approval.

Hip Impingement (FAI) Surgery in Ankara and Prof. Dr. Murat Bozkurt’s Approach

Hip impingement syndrome (FAI) is a significant cause of hip pain among the young and active population in Ankara and requires accurate diagnosis and treatment. Prof. Dr. Murat Bozkurt adopts the following approach in treating FAI:

• Accurate Diagnosis: He arrives at an accurate diagnosis using the patient’s history, a detailed physical examination, and, in particular, X-rays showing FAI morphology together with MR arthrography showing soft tissue damage.
• Comprehensive Evaluation: Rather than focusing only on the labrum or only on the bone, he evaluates all components of FAI (Cam, Pincer, labral damage, cartilage damage) as a whole.
• Minimally Invasive Surgery: When treatment is needed, he aims to treat both the bony impingement (osteoplasty) and the labral tear (repair) in the same session using minimally invasive arthroscopic surgery.
• Patient-Centered Care: He develops the most appropriate treatment plan based on the patient’s age, activity level, and expectations, and provides detailed information and guidance about the long post-operative rehabilitation process.