What is the treatment for pincer type morphology in femoroacetabular impingement (FAI)?

Treatment of Pincer-Type Femoroacetabular Impingement

Arthroscopic acetabular rim trimming with labral preservation and repair is the definitive treatment for symptomatic pincer-type FAI, addressing both the bony over-coverage and associated labral damage. 1

Diagnostic Confirmation Before Treatment

Before proceeding with treatment, confirm the diagnosis requires all three components 2:

• Hip-related groin pain (the hallmark symptom) 2
• Positive clinical examination (FADIR test has good sensitivity) 2
• Imaging confirmation showing lateral center edge angle (LCEA) >40° on plain radiographs 3, 2

A critical pitfall: Never treat imaging findings alone—pincer morphology is common in asymptomatic individuals and does not warrant intervention without corresponding symptoms and clinical signs. 3, 4

Initial Conservative Management

For patients meeting diagnostic criteria, begin with a 3-6 month trial of conservative treatment 4:

• Activity modification to avoid repetitive deep hip flexion and internal rotation movements 4
• Physical therapy focusing on hip stabilization and avoiding provocative positions 4
• NSAIDs for symptomatic relief during acute episodes 4

Surgical Indications

Proceed to surgical intervention when 4, 1:

• Conservative management fails after 3-6 months of appropriate therapy 4
• Persistent hip-related pain with positive clinical examination findings 4
• MRI or MR arthrography demonstrates labral tears or chondral damage requiring concurrent treatment 4

Surgical Technique: Arthroscopic Approach

The preferred surgical method is hip arthroscopy with the following algorithmic steps 1, 5, 6:

Step 1: Acetabular Rim Trimming (Acetabuloplasty)

• Remove the bony over-coverage causing the pincer effect by trimming the acetabular rim 1, 7
• Eliminate acetabular retroversion or protrusion if present 7
• Address the pathological contact between the acetabular rim and femoral head-neck junction 1

Step 2: Labral Management

• Always preserve and repair the labrum with sutures—this is non-negotiable 1
• Only sacrifice the labrum in extreme cases where preservation is impossible 1
• The labrum must be detached to perform rim trimming, then reattached 3

Step 3: Address Associated Pathology

For concurrent chondral lesions 3, 4:

• Grade 2-3 lesions <3 cm²: Perform microfracture, which produces substantially higher functional scores than chondroplasty alone 4
• Grade 4 defects: Microfracture achieves 93% defect fill with good-quality fibrocartilage 4
• Larger defects >2 cm² with Tönnis grade 2 osteoarthritis: Consider matrix-assisted autologous chondrocyte implantation (MACI) 4

For delaminated cartilage lesions 3:

• Lesions <3 cm²: Resect and perform microfracture 3
• Healthy-appearing flaps: Attempt repair with sutures or fibrin adhesive 3

When to Consider Open Surgical Dislocation

Open surgical dislocation remains indicated when 5:

• Concern exists for inability to fully access the morphology arthroscopically 5
• Severe acetabular retroversion requires extensive rim work 5
• Combined cam and pincer deformities are too complex for arthroscopic management 5

Note: Open approaches carry risk of femoral head osteonecrosis 3

Critical Management Pitfalls

Inadequate bony resection is the most frequent cause of revision surgery after arthroscopic FAI treatment. 5 Ensure complete correction of the pincer morphology during the index procedure.

Respect labral healing time during post-operative mobilization—premature aggressive motion can disrupt the repair. 1

High percentage of cases have concurrent cam morphology (mixed FAI)—always assess and address both components when present. 1, 8

Expected Outcomes

Short- to mid-term results are satisfactory in 75-80% of patients following arthroscopic treatment. 7 However, the presence of degenerative lesions in approximately two-thirds of patients at the time of surgery limits the probability of achieving good long-term results. 7