From the Guidelines
Managing pincer-type femoroacetabular impingement (FAI) visible on hip X-ray requires a comprehensive approach, prioritizing joint preservation and symptom alleviation, with surgical intervention considered for symptomatic patients who fail conservative management, as supported by the principles outlined in 1.
Initial Assessment and Management
The initial step in managing pincer-type FAI involves careful radiographic assessment, including standard anteroposterior pelvis and lateral hip X-rays to evaluate for acetabular overcoverage, which may present as acetabular retroversion, coxa profunda, or protrusio acetabuli. Key radiographic signs to look for include the crossover sign, posterior wall sign, and ischial spine sign. The lateral center-edge angle should be measured, with values greater than 40° suggesting pincer impingement, as noted in the context of hip preservation strategies 1.
Conservative Management
For symptomatic patients with confirmed pincer FAI, initial management should focus on conservative measures, including activity modification to avoid exacerbating the condition, physical therapy to enhance core strengthening and hip mobility, and the use of NSAIDs like ibuprofen or naproxen for pain control. These measures aim to alleviate symptoms and potentially delay the progression of the condition, aligning with the principles of managing chondral injuries and other intra-articular pathologies discussed in 1.
Surgical Intervention
If conservative measures fail to provide adequate symptom relief after 3-6 months, surgical intervention may be considered. The goal of surgery, typically arthroscopic or open acetabular rim trimming, is to reduce acetabular overcoverage while preserving joint stability. This approach is consistent with the joint-preserving surgical options discussed for the management of chondral injuries of the hip in 1, emphasizing the importance of early intervention to preempt degeneration of the entire joint, particularly in younger patients.
Follow-Up and Monitoring
Regular follow-up imaging is crucial to monitor for progression of hip osteoarthritis, a potential complication of pincer impingement due to the abnormal contact between the acetabular rim and femoral neck. This ongoing assessment allows for the adjustment of treatment plans as necessary to optimize patient outcomes, reflecting the complex and challenging nature of managing articular cartilage damage and related conditions, as highlighted in 1.
From the Research
Management of Pincer-Type Femoroacetabular Impingement (FAI)
To manage a pincer-type FAI visible on hip X-ray, the following options can be considered:
- Arthroscopic hip surgery, including reshaping the hip, as studied in 2 and 3
- Physiotherapist-led conservative care, as compared to hip arthroscopy in 2
- Nonoperative treatment, including activity modification and physical therapy, as discussed in 4
Diagnostic Considerations
Diagnosis of pincer-type FAI can involve:
- Plain radiographs
- Magnetic resonance imaging
- 3-dimensional computerized tomography
- Diagnostic injections, as mentioned in 5
Arthroscopic Management
Arthroscopic management techniques for pincer-type FAI can include:
- Acetabular rim trimming
- Labral debridement or repair/refixation
- Proximal femoral osteoplasty, as described in 3
- Patient-specific analysis of location of impingement using 3D-CT, as discussed in 6
Outcomes
Studies have shown significant improvement in outcomes measures after arthroscopic management of FAI, including: