Understanding FAI and choosing surgical candidates carefully are critical for success

Jennie McKee

Many different factors affect the ability of a professional athlete to return to high-level activities after femoral acetabular impingement (FAI) surgery, according to Marc J. Philippon, MD, who spoke at the Arthroscopy Association of North America 2012 Specialty Day program.

Orthopaedists must understand the movements involved in an athlete’s sport, said Dr. Philippon, and must perform a careful evaluation to determine whether an athlete is a good surgical candidate. He also noted that patients must follow rehabilitation protocols and that orthopaedic surgeons should manage players’ expectations after FAI surgery.

Understanding FAI in athletes
According to Dr. Philippon, elite athletes have a significantly greater incidence of FAI than the general population. FAI is classified into three types—pincer (acetabular rim impingement), cam (femoral sided impingement), and mixed.

“We know that rotational movements are associated with capsular laxity, as well as with labral tears,” he said. “Males have a higher predisposition to cam FAI, while females have a higher incidence of pincer FAI. Overall, mixed FAI is most common.”

Dr. Philippon underscored the importance of understanding the movements a patient performs.

“When evaluating an athlete, it’s important to understand the maneuvers he or she must perform, as well as the injury risks,” he said. For example, a hockey goal tender must repeatedly drop to his knees to protect the goal, while a baseball pitcher loads the back leg as the throwing motion is initiated, then lowers the front leg as it is completed, putting the hips at risk.

Ballerinas also put their hips at risk for FAI by hyperextending and hyperflexing the hip, as well as by excessively rotating the joint.

“Some of the positions ballerinas must assume can lead to very serious problems if the joint environment is restricted due to pincer or cam impingement, or even just instability,” he said.

Surgical outcomes
According to Dr. Philippon, many studies suggest that professional athletes who undergo surgical treatment for FAI have good surgical outcomes and can return to play promptly.

One study by Dr. Philippon and colleagues involved 28 professional hockey players who underwent arthroscopic labral repair for FAI between March 2005 and December 2007. Modified Harris Hip Score (MHHS) scores were obtained for all of the athletes preoperatively and postoperatively; the patients also completed a patient satisfaction questionnaire postoperatively.

“That specific population had a very large average alpha angle, and many patients also had radiographic evidence of pincer impingement,” he said. “They all had chondrolabral pathology.”

The average time from date of onset of symptoms to date of surgery was 19 months (range, 1 month to 99 months). After surgery, patients returned to sport at an average of 3.8 months (range, 1 month to 11 months). MHHS scores improved from a preoperative average of 70 to a postoperative average of 95 (range, 74–100) at an average of 24 months follow-up.

Based on the results of this study, he noted, surgically treating FAI and labral lesions in professional hockey players results in good outcomes, with patients able to return to sport quickly.

“We also found a correlation between time from injury to surgery and time required for rehabilitation,” he said. “The earlier a patient underwent surgery, the faster he recovered after treatment.”

Dr. Philippon and colleagues also conducted a retrospective review of 34 elite soccer, hockey, basketball, football, tennis, and golf players who underwent arthroscopic microfracture of the hip to treat FAI between 1999 and 2008. The patients had a discrete Outerbridge grade IV chondral lesion either on the femoral head (n=3), acetabulum (n=27), or both (n=4).

“In that difficult cohort of patients, microfracture and treating the associated FAI pathology enabled 27 of the 34 patients to return to play at an elite level,” said Dr. Philippon, “Those who returned to play continued to play for an average of 4 seasons. All but one of the 27 patients who returned to elite play did so the same season or the season following arthroscopic microfracture.”

Evaluating and treating patients
To obtain similar outcomes, said Dr. Philippon, orthopaedic surgeons should perform careful patient evaluations. Surgeons should look for labral tears, large alpha angles, and signs of painful apprehension on examination.

“Good candidates for returning to high-level activity are those who have been symptomatic for less than 1 year and have been unable to perform activity or sport based on subjective symptoms,” he said. “The patient should also have well-defined FAI, good articular status, and an MHHS of 60 or higher, with good muscular strength and a healthy body mass index.”

He recommended avoiding the use intra-articular steroid injections, which may reduce pain and swelling, but mask symptoms of FAI.

“If symptoms persist despite modification of training and the athlete is unable to perform at previous high levels, surgical intervention is warranted,” he said. “Delaying surgery may result in cartilage damage that could shorten the player’s athletic career.”

Dr. Philippon also stressed the importance of postoperative physical rehabilitation and communication.

“Rehabilitation is critical to success,” he said. “Athletes must not rush the rehabilitation protocol.”

In addition, he said, the surgeon must manage the player’s expectations.

“Talk to patients about the pathology so that they understand, and make sure to communicate clearly with all members of the medical staff, the player, and the team,” he said.

Jennie McKee is a staff writer for AAOS Now. She can be reached at mckee@aaos.org

Disclosure: Dr. Philippon reports ties to Smith & Nephew, Bledsoe, Donjoy, Arthrosurface, Hipco, MIS, Ossur, Arthrex, Siemens, SLACK Incorporated, and Elsevier.

Bottom Line

• Orthopaedists should understand the FAI risk factors unique to a professional athlete’s sport.
• According to Dr. Philippon, good surgical candidates for returning to high-level activity include those who have been symptomatic for less than 1 year and have the following characteristics: well-defined FAI, good articular status, an MHHS score of 60 or higher, good preoperative muscular strength, and a healthy body mass index.
• If symptoms persist and the athlete is unable to perform at previous high levels despite training modifications, surgical intervention is warranted.
• Managing players’ expectations and encouraging adherence to rehabilitation protocols are key.