Latest / Deep Dive Ortho — Orthopaedic Surgery, AI & Digital Health Podcast. / Femoroacetabular Impingement: Understanding Hip Pain and Treatment

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Femoroacetabular Impingement: Understanding Hip Pain and Treatment · Deep Dive Ortho — Orthopaedic Surgery, AI & Digital Health Podcast.

• 0:00
  Imagine this for a moment. You're active, maybe
• 0:02
  really dedicated to a sport, perhaps football,
• 0:05
  running, dance, whatever it is, or maybe you
• 0:06
  just love being active. And then, this ache starts,
• 0:11
  deep in your hip, maybe you're groin, not from
• 0:13
  a specific injury, it just creeps up. Sometimes
• 0:16
  it's sharp, especially after activity or even
• 0:18
  just sitting for a while. It's a very common
• 0:20
  story, unfortunately. And you live with it for
• 0:21
  months, maybe years, adjusting how you move,
• 0:24
  hoping it'll go away. but it often doesn't. Well,
• 0:27
  that nagging pain, that mechanical niggle might
• 0:30
  be femurocetabular impingement or FAI. Indeed.
• 0:34
  It affects a huge number of symptomatic athletes,
• 0:37
  maybe 55%. But it's also present, often silently,
• 0:41
  in about 10, 15 % of the general adult population.
• 0:44
  Today, we're diving deep into FAI. I'm your host,
• 0:47
  here to navigate through the complex details,
• 0:49
  and I'm joined by our expert, Jest. He has this
• 0:52
  fantastic ability to take really complex medical
• 0:55
  information, see the patterns, and explain it
• 0:57
  all in a way that makes sense. It's great to
• 0:58
  be here. The hip joint really is an incredible
• 1:01
  structure, designed for both power and subtle
• 1:03
  movement. But yeah. even small changes in its
• 1:06
  shape can cause significant problems like FAI.
• 1:09
  Absolutely. And that's our mission today to really
• 1:11
  get under the skin of femurocetabular impingement.
• 1:15
  We'll look at what it is, the different types,
• 1:17
  who gets it, why they get it, and crucially,
• 1:20
  how it's diagnosed and what the latest treatment
• 1:22
  options look like from physio right through to
• 1:24
  surgery and what it all means for long term hip
• 1:28
  health. So let's get stuck in. OK, let's start
• 1:32
  right at the beginning. Femoral acetabular impingement,
• 1:36
  FAI. What exactly is it? It doesn't sound like
• 1:38
  a typical disease, does it? More like a physical
• 1:41
  fit issue. That's a very good way to put it,
• 1:43
  actually. It's not a disease like an infection.
• 1:46
  It's what we call a pathomechanical process.
• 1:47
  It's half a mechanical, right? Yeah. Think of
• 1:49
  your hip as a near -perfect ball and socket joint.
• 1:52
  You have the femoral head, the ball at the top
• 1:54
  of your thigh bone, fitting snugly into the acetabulum,
• 1:57
  which is the socket in your pelvis. Normally,
• 1:59
  they glide smoothly. In FAI, that smooth gliding
• 2:03
  is disrupted. You get abnormal contact, basically.
• 2:07
  The femur and the acetabulum repeatedly collide
• 2:10
  or rub against each other incorrectly during
• 2:12
  movement. A collision. Exactly, a mechanical
• 2:14
  collision. And this isn't gentle. It's often
• 2:17
  a forceful pinching or grinding. Over time, this
• 2:21
  constant abnormal contact starts to cause damage.
• 2:24
  Damage to what, specifically? Well, typically
• 2:27
  the first structure to suffer is the labrum.
• 2:29
  That's a ring of strong fiber cartilage around
• 2:31
  the rim of the socket. Right. Think of it like
• 2:33
  a gasket or a seal. Okay. the rubbing damages
• 2:35
  it, causes tears, then the articular cartilage,
• 2:39
  that incredibly smooth white lining in the bone
• 2:41
  surfaces that lets them glide, that gets injured
• 2:43
  too. Right, the slippery stuff. Precisely. And
• 2:45
  this ongoing damage, this mechanical insult,
• 2:48
  is what leads to the progressive hip pain and
• 2:50
  stiffness that people experience. So yes, fundamentally,
• 2:52
  it's a problem of shape and mechanics. That makes
• 2:54
  sense. And you mentioned different types, that
• 2:56
  this extra bone or abnormal shape shows up in
• 2:59
  distinct ways. That's right. Although the underlying
• 3:02
  issue is this abnormal bone shape causing the
• 3:05
  collision, where that abnormality is located,
• 3:08
  defines the type, and often correlates with who
• 3:11
  tends to get it. We generally talk about two
• 3:13
  main types, though very often people have a mix
• 3:15
  of both. OK. The first is cam impingement. The
• 3:18
  name comes from engineering, like a camshaft
• 3:22
  that isn't perfectly round. Ah, OK. This is a
• 3:24
  femoral based disorder. The problem is on the
• 3:27
  ball side, the femur. We tend to see this more
• 3:29
  in young athletic males. Young men, okay. Yes.
• 3:33
  Essentially, the femoral head, or usually the
• 3:35
  junction between the head and the neck, isn't
• 3:37
  perfectly spherical. It's a bit aspherical or
• 3:41
  too broad, often with a characteristic bump on
• 3:44
  the front outer side. A bump on the ball. Exactly.
• 3:46
  We're talking about a decreased head -to -neck
• 3:48
  ratio or offset. Basically, the smooth contour
• 3:51
  is lost. Now imagine this non -spherical ball
• 3:54
  trying to move fully within the socket. It's
• 3:56
  gonna jam, isn't it? Precisely. As a hip flexes
• 3:59
  and rotates inwards, that bump, the cam lesion,
• 4:03
  effectively levers against the rim of the socket.
• 4:05
  This creates a shearing force right where the
• 4:08
  cartilage meets the labrum. Ouch. Yes. Instead
• 4:11
  of gliding, it peels the cartilage away from
• 4:15
  the bone that's cartilage delamination, and it
• 4:17
  can tear the labrum, causing labral separation.
• 4:20
  On x -rays, you might see what's called a pistol
• 4:22
  grip deformity because of the shape. Pistol grip.
• 4:25
  Got it. So that's cam. What's the other type?
• 4:27
  The second type is pincer impingement. This is
• 4:29
  an acetabular -based disorder. The issue lies
• 4:32
  with the socket, the acetabular. So the socket's
• 4:34
  the problem this time. Correct. We tend to see
• 4:36
  this more frequently in active middle -aged women.
• 4:39
  Here, the socket rim has too much coverage, an
• 4:42
  overhang, usually at the front and top part.
• 4:44
  Too much socket. In effect, yes. It might be
• 4:47
  because the socket itself is angled slightly
• 4:48
  backwards, it's acetabular retroversion, or it
• 4:51
  might be just generally too deep, what we call
• 4:53
  acetabular protrusia or coxoprofinda. So with
• 4:56
  pincer, when the hip flexes, instead of the bump
• 4:59
  shearing things, the overhanging rim of the socket
• 5:01
  directly pinches or crushes the labrum against
• 5:05
  the femoral neck. Crushing the seal. Exactly.
• 5:07
  This often causes tearing within the substance
• 5:10
  of the labrum itself. And interestingly, You
• 5:13
  can get what's called a contracoup cartilage
• 5:15
  injury. Contracoup? Like in head injuries? Similar
• 5:18
  principle. As the front of the neck hits the
• 5:20
  overhanging socket rim, it levers the back of
• 5:23
  the femoral head against the back wall of the
• 5:25
  socket, damaging the cartilage there opposite
• 5:27
  the main impingement site. Wow. Okay. Any specific
• 5:31
  signs on x -ray for pincer? A classic one, especially
• 5:34
  with retroversion, is the crossover sign on a
• 5:37
  pelvis x -ray. where the front and back walls
• 5:39
  of the socket seemed to cross over. Right, CAM
• 5:41
  and PINCER. But you said people often have both.
• 5:43
  Yes, absolutely. It's really important to stress
• 5:45
  that. Combined impingement, a mix of both CAM
• 5:48
  and PINCER features, is actually the most common
• 5:50
  scenario we see in symptomatic patients, perhaps
• 5:53
  up to 80 % of cases. So often, we need to address
• 5:56
  both aspects surgically. OK. That's clear. These
• 5:59
  aren't just minor anacomical quirks then. They
• 6:01
  cause real mechanical problems. And it sounds
• 6:04
  like this isn't just about the immediate pain
• 6:06
  of that collision. It sets off a kind of chain
• 6:09
  reaction, doesn't it? Leading to bigger problems
• 6:11
  down the line. Precisely. That's the critical
• 6:14
  thing to understand about the long -term picture.
• 6:16
  The immediate pain is from the pinching and rubbing,
• 6:19
  yes. But it's the chronic, repetitive nature
• 6:22
  of that mechanical collision that does the real
• 6:25
  damage over time. This constant friction, whether
• 6:29
  it is shearing from a cam lesion or crushing
• 6:31
  from a pincer, leads to progressive labral degeneration
• 6:34
  and tears. The labrum just isn't designed to
• 6:37
  withstand that kind of abuse, so it wears down
• 6:39
  phrase tears. And the cartilage too. And the
• 6:42
  cartilage, too. That smooth gliding surface suffers
• 6:45
  significant cartilage damage. It might soften,
• 6:49
  fray, develop blisters, or even full thickness
• 6:51
  tears or flaps. And the trouble with articular
• 6:53
  cartilage is its very limited ability to heal
• 6:56
  itself. It doesn't repair well. Not really, no.
• 6:59
  So over time, this relentless wear and tear transforms
• 7:03
  localized damage into broader joint degeneration.
• 7:07
  which is why FAI is now recognized as a major
• 7:10
  known risk factor for the development of osteoarthritis
• 7:13
  of the hip. Ah, so it leads to arthritis earlier.
• 7:16
  It certainly seems to accelerate the process,
• 7:19
  yes, leading to hip dysfunction and potentially
• 7:21
  the need for hip replacement surgery much earlier
• 7:24
  in life than we might otherwise expect. It's
• 7:27
  a pathway from subtle shape difference to significant
• 7:30
  joint failure, potentially. That's quite sobering.
• 7:32
  So if these bone shapes are the root cause, what
• 7:34
  causes them? Is it something you're born with?
• 7:36
  Is it genetics, or does activity play a role?
• 7:39
  You mentioned athletes. It's a really key question.
• 7:41
  And the honest answer is we're still figuring
• 7:43
  out all the details. But the current thinking
• 7:45
  points towards a combination of factors. It's
• 7:47
  rarely just one thing. Firstly, there does seem
• 7:50
  to be a genetic predisposition. Research suggests
• 7:53
  genetic factors may contribute. Specific small
• 7:57
  variations in our DNA, things called SNPs, single
• 8:00
  nucleotide polymorphisms, tiny genetic differences,
• 8:04
  some. like variants in genes called GDF5, FRZB,
• 8:08
  DI02, HOX9, have been linked to particular hip
• 8:12
  shapes, both on the femur and socket side, and
• 8:15
  also to an increased risk of developing osteoarthritis.
• 8:18
  So your genes can literally shape your hip in
• 8:21
  a way that makes FAI more likely. It seems that
• 8:23
  way, yes. It sets the stage, potentially. Interesting.
• 8:26
  And the athlete connection, does playing sport
• 8:28
  cause it? That's the athlete paradox, as you
• 8:30
  called it. We definitely see more FAI, particularly
• 8:33
  the cam type in athletes. But, and this is really
• 8:36
  crucial, exercise does not cause FAI in a normal
• 8:39
  hip. Okay, that's important. Yes. The leading
• 8:41
  theory is that during adolescence, when the bones
• 8:43
  are still growing and developing, the increased
• 8:45
  stress along the great plate of a hip from high
• 8:47
  intensity sports, think repetitive deep flexion,
• 8:50
  rotation, like in football, hockey, martial arts,
• 8:53
  might trigger a sort of stress reaction. The
• 8:55
  bone reacts to the stress? Exactly an increased
• 8:58
  stress reaction bone formation the body adapts
• 9:01
  by laying down more bone But in this area it
• 9:04
  can result in that cam deformity that bump So
• 9:07
  intense activity during those key growth years
• 9:10
  and someone perhaps already predisposed might
• 9:12
  lead to the shape forming So activity doesn't
• 9:15
  cause it from scratch, but it can contribute
• 9:16
  to the shape developing, or at least make an
• 9:19
  existing shape symptomatic earlier. Precisely.
• 9:22
  If you already have that subtle anatomical difference,
• 9:25
  vigorous activity involving lots of hip movement
• 9:27
  will provoke the impingement more often and more
• 9:29
  forcefully, leading to symptoms sooner. It unmasks
• 9:33
  the problem. Right. Are there other factors?
• 9:35
  Childhood conditions? Yes, definitely. Childhood
• 9:38
  influences are important. A history of slipped
• 9:40
  capital femoral bypasses or SEFE is a major one.
• 9:45
  That's where the ball part slips off the thigh
• 9:47
  bone at the growth plate during childhood. Even
• 9:49
  after it's fixed surgically, the residual shape
• 9:51
  change, the deformity, can directly cause impingement
• 9:55
  later in life. Other conditions like perthase
• 9:57
  disease, which affects blood supply to the hip
• 10:00
  in childhood, and hip dysplasia, where the socket
• 10:03
  is too shallow, are also linked to a higher chance
• 10:05
  of developing FAI. So it's often multifactorial.
• 10:09
  Genetics, developmental stress, maybe previous
• 10:12
  hip issues. OK, that makes sense. But then...
• 10:14
  If these shapes are actually quite common, as
• 10:16
  you said earlier, why do some people have terrible
• 10:18
  symptoms while others with the same x -ray findings
• 10:21
  feel Absolutely fine. It's confusing. It is confusing
• 10:24
  and it's a huge area of research You're right.
• 10:27
  The prevalence of the bone shapes is surprisingly
• 10:29
  high We mentioned 10 15 percent in the general
• 10:31
  population having the morphology But remember
• 10:34
  that study the meta -analysis by Frank at all
• 10:36
  They found cam deformity in 37 percent and pincer
• 10:40
  deformity in a massive 67 percent of asymptomatic
• 10:43
  volunteers people with no hip pain at all 67
• 10:45
  percent Wow Exactly. So a huge number of people
• 10:48
  are walking around with these FAI bone shapes
• 10:51
  without any symptoms. The morphology itself doesn't
• 10:54
  automatically equal pain. We also see those gender
• 10:57
  differences in prevalence can more in men, pincer
• 10:59
  more in women. But again, many are asymptomatic.
• 11:03
  So what's the tipping point? Why do symptoms
• 11:05
  start for some people? The general consensus
• 11:07
  is that symptoms develop when the mechanical
• 11:10
  collision finally starts causing significant
• 11:12
  damage to the cartilage or the labrum. It's when
• 11:15
  those soft tissues, which have nerve endings,
• 11:18
  start to break down under the repetitive strain.
• 11:20
  Ah, so it's the damage, not just the shape. Exactly.
• 11:23
  The onset of pain, clicking stiffness that usually
• 11:26
  signals that the pathological process is now
• 11:29
  actively injuring the joint structures. And once
• 11:31
  that happens, if the impingement continues, the
• 11:34
  condition is likely to worsen. The damage progresses.
• 11:37
  Having the shape is one thing. Having symptoms
• 11:39
  means the joint is now suffering. Right. Which
• 11:41
  brings us neatly to diagnosis. For someone with
• 11:44
  that nagging hip or groin pain, what are the
• 11:46
  telltale signs? How do doctors start to suspect
• 11:49
  FAI specifically, given hip pain can be so vague?
• 11:52
  It can be very vague, you're right. That's why
• 11:54
  a careful history and a thorough physical exam
• 11:57
  are absolutely paramount. What do patients typically
• 11:59
  report? Usually a gradual onset of hip pain.
• 12:03
  It's often not a sudden thing. The location is
• 12:06
  most commonly deep in the groin area, but as
• 12:08
  we said, it can radiate to the thigh, buttock,
• 12:11
  outer hip, even the back. The C sign? Yes. Often
• 12:14
  they'll use that characteristic C sign, cupping
• 12:17
  their hand around the side in front of the hip
• 12:18
  to show where it hurts. That's quite suggestive
• 12:21
  of something inside the joint. Okay. And what
• 12:23
  makes it worse? Classically, pain is exacerbated
• 12:27
  by hip flexion and internal rotation. So activities
• 12:30
  involving those movements, high intensity sports,
• 12:34
  squatting, getting in and out of cars, driving,
• 12:37
  even just sitting for prolonged periods. Makes
• 12:39
  sense that position forces the joint together.
• 12:41
  Exactly. They might also report mechanical hip
• 12:44
  symptoms, things like clicking, catching, locking,
• 12:47
  or a popping sensation. That strongly suggests
• 12:49
  a labral tear is involved. And during the physical
• 12:52
  exam, what are you looking for? We look for restricted
• 12:55
  movement. Often there's limited hip flexion and
• 12:58
  particularly limited internal rotation, especially
• 13:00
  when the hip is flexed to 90 degrees. Sometimes
• 13:03
  internal rotation is less than five degrees.
• 13:05
  Wow, very restricted. Yes, and the key provocative
• 13:09
  test is the anterior impingement test or FEI
• 13:12
  or test. We gently flex the hip to 90 degrees.
• 13:15
  bring it across the body slightly, adduction,
• 13:18
  and then rotate it inwards. And if that hurts?
• 13:20
  If that reproduces their specific pain, it's
• 13:22
  a positive test. It's highly sensitive, positive
• 13:25
  in about 88 % of patients with FAI. It really
• 13:29
  hones in on that specific conflict zone. OK.
• 13:32
  So history and exam give a strong suspicion.
• 13:35
  Then comes imaging, presumably, to confirm it
• 13:37
  and see the extent of the problem. Absolutely.
• 13:40
  Imaging is essential to confirm the bony shapes
• 13:42
  and, critically, to assess the state of the labrum
• 13:45
  and cartilage. It completes the picture and guides
• 13:47
  treatment. What imaging do you start with? We
• 13:50
  always begin with radiographs, standard x -rays.
• 13:52
  A specific set of views is needed. a standing
• 13:54
  AP pelvis view, an AP view of the affected hip,
• 13:57
  and a good lateral view of the hip. What do these
• 13:59
  show? They allow us to assess the bone structure,
• 14:01
  looking for those cam and pincer lesions. We
• 14:04
  look for the pistol grip deformity for cam, signs
• 14:06
  of over coverage, like the crossover sign for
• 14:08
  pincer, or maybe a deep socket protrusio. And
• 14:12
  you measure things on the x -rays? Yes. Precise
• 14:14
  measurements are key. The alpha angle, usually
• 14:17
  measured on a special lateral view, like a dun
• 14:19
  or frog leg view, quantifies the cam deformity.
• 14:23
  An angle over 50 -55 degrees is generally considered
• 14:26
  abnormal. We also measure acetabular coverage
• 14:29
  with things like the lateral center edge angle.
• 14:32
  An angle below 25 degrees might suggest dysplasia.
• 14:35
  not enough coverage, which is different from
• 14:37
  FAIs over coverage. Different views like the
• 14:40
  done view are best for seeing the cam lesion,
• 14:42
  while a false profile view helps assess coverage
• 14:44
  at the front. So x -rays give the bony blueprint.
• 14:47
  What about CT scans? CT scans can be a useful
• 14:50
  adjunct. They give incredibly detailed views
• 14:53
  of the structural abnormalities and allow for
• 14:55
  amazing 3D reconstructions. These are fantastic
• 14:58
  for preoperative planning, letting the surgeon
• 15:00
  really visualize the shape and plan the bone
• 15:01
  resection. The downside is the higher radiation
• 15:04
  dose. Right. And for the soft tissues, the labrum
• 15:07
  and cartilage. For that, MRI is the gold standard.
• 15:11
  Specifically, MR arthrography is often preferred.
• 15:15
  Arthrography. That involves an injection, doesn't
• 15:17
  it? Yes, exactly. An intraarticular contrast
• 15:20
  injection, a special dye, is put into the hip
• 15:22
  joint just before the MRI scan. This dye leaks
• 15:25
  into any tears or defects in the labrum or cartilage,
• 15:28
  making them show up much more clearly. It's the
• 15:31
  best modality to evaluate for articular cartilage
• 15:34
  and labral damage. It makes sense. MRI also shows
• 15:37
  the bone shape well, without radiation, and it's
• 15:40
  excellent for ruling out other causes of hip
• 15:42
  pain that might mimic FAI. like a vascular necrosis,
• 15:46
  stress fractures, or various types of tendonitis.
• 15:48
  So MRI is really comprehensive. Is there anything
• 15:51
  else diagnostically? One other tool is a diagnostic
• 15:54
  intraarticular injection of local anesthetic.
• 15:56
  We numb the hip joint directly. If the patient's
• 15:59
  pain significantly improves, even temporarily,
• 16:02
  it strongly confirms the pain is coming from
• 16:04
  inside the joint, likely the FAI. It can be very
• 16:06
  helpful when the picture isn't perfectly clear.
• 16:08
  That's a really thorough diagnostic process.
• 16:11
  So once FAI is confirmed, surgery isn't automatically
• 16:14
  the next step, is it? What about conservative
• 16:17
  approaches? No, absolutely not. Non -surgical
• 16:19
  management is always the first port of call,
• 16:22
  especially for patients who are minimally symptomatic
• 16:25
  or don't have those definite mechanical symptoms
• 16:28
  like locking. What does that involve? It's usually
• 16:30
  a combination approach. Firstly, activity modification.
• 16:34
  This means identifying and reducing or temporarily
• 16:37
  stopping activities that provoke the pain. Not
• 16:41
  stopping everything, but being smarter about
• 16:43
  movement. Avoiding the triggers. Exactly. Secondly,
• 16:46
  and crucially, targeted physical therapy. A good
• 16:49
  physio will assess movement patterns, look for
• 16:52
  weaknesses or imbalances in the kinetic chain,
• 16:54
  and work on improving hip range of motion and
• 16:56
  strengthening the surrounding muscles, glutes,
• 16:59
  core muscles. To support the joint better. Precisely.
• 17:02
  Better control, better mechanics can sometimes
• 17:04
  reduce the stress on the impingement zone. Thirdly,
• 17:08
  pain management, mainly with NSAID's non -steroidal
• 17:10
  anti -inflammatory drugs to reduce pain and inflammation.
• 17:13
  Like ibuprofen. Yes. And as we mentioned that,
• 17:17
  intraarticular injection of local anesthetic
• 17:19
  and steroid can be used therapeutically too.
• 17:22
  The steroid reduces inflammation inside the joint,
• 17:25
  providing pain relief that can last weeks or
• 17:27
  months, making physio more effective. But these
• 17:30
  don't fix the underlying shape, do they? No,
• 17:33
  and that's the critical limitation. Conservative
• 17:35
  measures manage the symptoms, they manage the
• 17:38
  inflammation, they might improve mechanics around
• 17:40
  the problem, but they don't change the bone shape.
• 17:43
  They don't stop the collision happening. So if
• 17:45
  these don't provide... lasting relief. Then surgery
• 17:49
  becomes the next consideration. If symptoms persist
• 17:52
  despite a good trial of conservative management,
• 17:54
  usually three to six months, or if mechanical
• 17:56
  symptoms are prominent, then we discuss addressing
• 17:59
  the underlying anatomy directly. Right. So tell
• 18:01
  us about the surgical options. What's the aim?
• 18:04
  The aim of surgery is to reshape the bones, the
• 18:07
  femur, the acetabulum, or both, to eliminate
• 18:10
  the abnormal contact, the impingement, basically
• 18:13
  to restore normal hip mechanics and allow smooth,
• 18:16
  pain -free movement. They're two main approaches.
• 18:18
  The most common approach now is arthroscopic
• 18:21
  osteoplasty. This is minimally invasive, done
• 18:24
  through small keyhole incisions using a camera,
• 18:27
  the arthroscoge, and specialized instruments.
• 18:29
  Keyhole surgery for the hip. Exactly. The surgeon
• 18:32
  can see inside the joint on a screen and precisely
• 18:36
  trim the bony rim of the acetabulum, if it's
• 18:39
  a pincer lesion, or shave down the bump on the
• 18:42
  femoral head or neck for a cam lesion. That's
• 18:46
  the osteoplasty part reshaping the bone. And
• 18:48
  they can fix the labrum at the same time? Yes,
• 18:50
  a huge advantage is that arthroscopy allows the
• 18:52
  surgeon to thoroughly assess and repair or clean
• 18:55
  out any damage to the labrum and articular cartilage
• 18:58
  as well. Studies show it gives equivalent results
• 19:01
  to open hip surgery, but often with a quicker
• 19:03
  return to activity. That sounds promising. What's
• 19:05
  the open surgery option? The alternative is open
• 19:08
  surgical hip dislocation. This is the previous
• 19:10
  gold standard. It involves a larger incision
• 19:13
  and a technique where part of the hip bone, the
• 19:15
  greater trochanter, is temporarily detached to
• 19:17
  allow the surgeon to safely dislocate the hip
• 19:20
  joint and get a wide direct view of the femoral
• 19:22
  head and socket. Sounds quite major. It is a
• 19:25
  bigger operation, yes, but it's designed very
• 19:28
  carefully to preserve the blood supply to the
• 19:31
  femoral head. So the risk of a vascular necrosis
• 19:35
  or AVN is very low. It provides excellent exposure,
• 19:39
  which can be really useful for significant femoral
• 19:42
  deformity or complex cases. Return to play rates
• 19:45
  for athletes after open surgery are historically
• 19:48
  very high, over 85 -90%, provided they don't
• 19:51
  already have significant arthritis. Okay, and
• 19:54
  regardless of the approach, dealing with the
• 19:55
  labrum is key, you said. Absolutely critical.
• 19:57
  If there's a labral tear, which there usually
• 20:00
  is in symptomatic FAI, it needs to be addressed
• 20:03
  repaired or sometimes reconstructed at the same
• 20:05
  time as the bone is reshaped. Just cleaning out
• 20:08
  the labral tear, isolated labral debridement,
• 20:10
  without fixing the underlying bony impingement
• 20:12
  simply doesn't work long -term. Because the cause
• 20:15
  is still there? Exactly. It's a major cause of
• 20:17
  treatment failures. You have to address both
• 20:19
  the bone shape and the soft tissue damage it's
• 20:21
  caused. Right. Are there other surgeries sometimes
• 20:23
  needed alongside? Occasionally, yes. If there's
• 20:26
  significant hip dysplasia or etabular retroversion,
• 20:30
  a more complex operation called a periocetabular
• 20:33
  osteotomy might be needed to reorient the socket.
• 20:36
  And if the joint is already badly worn out with
• 20:39
  end -stage arthritis, then hip arthroplasty,
• 20:42
  a total hip replacement, becomes the necessary
• 20:44
  solution. It really depends on the individual
• 20:46
  case. Okay. Now, surgery always carries risks.
• 20:50
  What are the potential complications people should
• 20:52
  be aware of with FAI surgery? And what's a realistic,
• 20:55
  long -term outlook? That's a crucial conversation
• 20:59
  to have with patients. While generally safe and
• 21:01
  effective, complications can occur. What are
• 21:03
  the main ones? Major, though thankfully rare,
• 21:06
  complications include things like femoral neck
• 21:07
  fracture, particularly during the bone reshaping
• 21:09
  for a cam lesion. Surgeons are very careful to
• 21:12
  limit how much bone they remove, generally less
• 21:14
  than 30 % of the femoral neck diameter, to minimize
• 21:17
  this risk. With arthroscopy, very rare risks
• 21:20
  include things like abdominal compartment syndrome
• 21:23
  from fluid leaking where it shouldn't, or nerve
• 21:26
  injury. Other potential major issues, though
• 21:29
  uncommon, are blood clots, DVTPE, deep infection,
• 21:33
  or dislocation after surgery. A vascular necrosis
• 21:37
  is a risk, though minimized by careful technique.
• 21:39
  And minor complications. These are more common,
• 21:42
  but usually manageable. Things like heterotopic
• 21:44
  ossification where extra bone forms in the soft
• 21:47
  tissues afterwards. We often give endocides like
• 21:50
  endomethacin post -operatively to help prevent
• 21:52
  this. Temporary nerve irritation or praxious
• 21:56
  causing numbness maybe in the thigh or perineal
• 21:58
  area from traction during arthroscopy can happen
• 22:01
  but usually resolves. Superficial infection or
• 22:04
  bruising are also possible. Okay and the long
• 22:06
  -term prognosis. Does surgery stop arthritis?
• 22:10
  That's the million dollar question, isn't it?
• 22:12
  We know the natural history of untreated FAI
• 22:14
  likely leads to early onset hip dysfunction and
• 22:17
  arthritis. Surgery definitely needs to change
• 22:19
  that course. It's very successful at reducing
• 22:21
  symptoms and improving function in the short
• 22:23
  to medium term, and it can prevent future damage
• 22:26
  by stopping the impingement. But... The current
• 22:29
  scientific evidence is still unclear whether
• 22:32
  it will definitively delay or prevent the development
• 22:35
  of hip arthritis in the very long run, say 15,
• 22:38
  20 years or more. So it might still happen later.
• 22:41
  It might. Patients need to understand that while
• 22:43
  surgery aims for joint preservation and symptom
• 22:45
  relief, they may still develop arthritis in the
• 22:48
  future and potentially need a hip replacement
• 22:50
  eventually. The goal is to push that possibility
• 22:53
  as far down the road as possible. or lessen its
• 22:56
  severity. That's important expectation setting.
• 22:59
  And after surgery, rehab is vital, I imagine.
• 23:02
  Absolutely essential. Post -operative rehabilitation
• 23:04
  is just as important as the surgery itself. It's
• 23:07
  a structured, progressive process guided by physical
• 23:10
  therapists. What does it involve? It starts with
• 23:13
  a period of protected weight -bearing, using
• 23:15
  crutches for maybe... two to six weeks depending
• 23:17
  on the surgery. Early passive range of motion
• 23:19
  starts almost immediately to stop stiffness.
• 23:22
  Then comes active range of motion followed by
• 23:24
  intensive strengthening exercises for the hip
• 23:26
  and core and gait training to normalize walking.
• 23:29
  Getting back to sport. That comes later usually
• 23:32
  after 12 weeks or so with gradual reintroduction
• 23:35
  of jogging, jumping and agility exercises. It's
• 23:39
  a careful progression tailored to the individual.
• 23:42
  The physio's role is absolutely critical in guiding
• 23:45
  this safely. It sounds like a long process. It
• 23:48
  requires patience and commitment, definitely.
• 23:50
  Finally, looking ahead, what's new in the world
• 23:52
  of FAI? Where is the research heading? It's a
• 23:55
  very active field. The number of scientific publications
• 23:58
  on FAI has exploded in the last 15 -20 years.
• 24:02
  We're seeing advancements like computer -based
• 24:04
  navigation systems being developed to help surgeons
• 24:07
  perform the bone resection even more accurately
• 24:09
  during arthroscopy. Improving precision. Exactly.
• 24:12
  But there's also an acknowledged need for more
• 24:14
  high quality research. We need more mechanistic
• 24:16
  studies to really understand why the damage occurs
• 24:19
  at a cellular level. And critically, we need
• 24:21
  more long -term outcome data studies following
• 24:24
  patients for many, many years to truly understand
• 24:27
  the natural course of FAI and the real long -term
• 24:30
  impact of non -surgical and surgical treatment
• 24:32
  on preventing arthritis. So still learning? Always
• 24:36
  learning, yes. but we've come a very long way
• 24:39
  in understanding and treating it effectively.
• 24:41
  This has been incredibly informative. It really
• 24:43
  drives home how complex hip pain can be stemming
• 24:46
  from these underlying mechanical issues. Just
• 24:49
  to summarize the key takeaways for everyone listening.
• 24:51
  Firstly, FAI isn't just pain, it's a mechanical
• 24:54
  clash in the hip caused by abnormal bone shapes,
• 24:58
  cam, pincer, or usually combined. Bone hitting
• 25:01
  bone where it shouldn't. Secondly, it's a clear
• 25:03
  risk factor for developing early hip osteoarthritis,
• 25:06
  especially in active people whose movements can
• 25:09
  accelerate the wear and tear. Correct. Thirdly,
• 25:12
  diagnosis hinges on specific clinical tests,
• 25:15
  like that FADR impingement test, combined with
• 25:18
  imaging x -rays for the bone shapes, MRI, often
• 25:20
  with dye to see the laboring and cartilage damage.
• 25:24
  Yes. Fourth, treatment starts conservatively
• 25:26
  with activity changes and physio, but precise
• 25:28
  surgery, often keyhole arthroscopy, can reshape
• 25:32
  the bones and repair soft tissues to fix the
• 25:34
  mechanical problem. That's the pathway. And finally,
• 25:37
  while surgery is good for symptoms and function
• 25:39
  now and can prevent further immediate damage,
• 25:42
  its ability to completely stop arthritis developing
• 25:45
  decades later is still being studied. It's about
• 25:48
  long -term joint preservation. Well summarized.
• 25:51
  If you found this deep dive helpful, we'd really
• 25:53
  appreciate it if you could take a second to rate
• 25:55
  the show or share it with someone who might find
• 25:57
  it useful, maybe someone you know dealing with
• 25:59
  persistent hip issues. And a final thought to
• 26:01
  leave you with. Just consider how these seemingly
• 26:04
  small variations in our anatomy, things we might
• 26:07
  not even know we have, can have such a huge impact
• 26:10
  on our movement, our quality of life, and our
• 26:12
  long -term joint health. It really highlights
• 26:15
  the importance of listening to our bodies and
• 26:17
  seeking answers when things don't feel right.