Dr. Grewal: Examining the likely surgery to Pavel Francouz

This is a new addition to Colorado Hockey Now, occasional pieces from Harjas S. Grewal, MD BSc. Family Medicine PGY-1 at the University of Manitoba. He also is a consultant with the Fantasy Doctors. When injuries to players happen, we’re told “upper body, lower body” and that’s it. Dr. Grewal’s occasional columns will give general overviews of various types of injuries, how they are treated and the prognosis for recovery. In his first column for CHN, Dr. Grewal discusses a common type of hip surgery given to hockey players – especially goalies – which may have been performed on Avalanche goalie Pavel Francouz. Avs GM Joe Sakic said recently that Francouz had the same kind of surgery as Semyon Varlamov in 2017. 

By Harjas S. Grewal, MD

Pavel Francouz was declared out for the remainder of the season this past week and we initially had that news. The Avalanche have not disclosed any details around the specifics of the injury or surgery. However, if he had the same procedure as Semyon Varlamov in 2017, then we can piece together the puzzle.

Varlamov had surgery on both hips four weeks apart in 2017 for a “groin injury”. So that begs the question, did he have a groin injury, hip injury, or both? Well further reports indicated that renowned hip surgeon Dr. Marc J. Philippon performed Varlamov’s procedure, and he would not typically perform surgery on the groin muscle or tendon, but rather the hip joint itself. Moreover, it’s not common for someone to have surgery on both hips but when someone does, it can be because they have a condition called femoral acetabular impingement (FAI) which has damaged their hip. Tying this information together, Varlamov likely had FAI, which caused problems with hip range of motion and pain secondary to damage to the hip labrum, joint cartilage, or both. 

So let’s back up a little bit. The hip joint works like a ball and socket, where the ball is the head of the thighbone (femur) and the socket is the acetabulum of the pelvis. Moreover, the head of the femur and the acetabulum are lined with cartilage to create a smooth surface between the bones. The joint is also supported by a labrum, which is a lining of soft tissue cupping the joint. Consequently, as someone moves their hip forward, backward, out to the side, and in a circular motion, the head of the femur typically slides around smoothly in the acetabulum without slipping out.

If someone has FAI, the thighbone (CAM deformity) or acetabulum (pincer deformity) has some extra bone that is getting in the way, or impinging, and causing the hip movement to not be smooth. When this movement is not smooth, the extra bone digs into the cartilage, labrum, or both, and damages it. Once this damage occurs, athletes will start feeling pain and, most often, they feel that pain in their groin area.

Some individuals may have FAI because they were born with it but bones also grow in response to stress and there have been studies which show that hockey players have more FAI than the general population. One theory is that years of skating causes this bone growth to form in response to stress to the hips. 

Francouz likely told the Avalanche medical staff that he had groin pain and/or decreased range of motion. After being examined and imaged, the Avalanche likely had the diagnosis made but opted to pursue first-line treatment, which would be physical therapy, to try and see if Francouz could rehab back to play. Ultimately, it seems that this approach was unsuccessful and so he had to go under the knife. 

The procedure for managing this involves making small incisions to insert a camera and surgical instruments into the joint. This is known as hip arthroscopy. The camera will project an image onto a screen and the surgeon will observe this while maneuvering tools inside the hip. The surgeon will then reshape the head of the femur and/or acetabulum by removing the excess bone so that the ball and socket fit together smoothly. If the labrum is torn, the surgeon will put it back together with sutures and anchors. If the cartilage is damaged, the surgeon will first remove any damaged cartilage and then will drill holes through the cartilage into the bone underneath to cause bleeding which allows the cartilage to repair itself. This is also known as microfracture surgery. 

Following this, the athlete will have to allow the incisions to heal and then begin a gradual rehab program that focuses on first increasing range of motion and then strengthening all of the muscles around the hip before returning to the ice. This typically takes around 6 months but can often take longer depending on the extent of damage and how they progress through the various stages of rehab. 

The good news is that players often return to perform at a similar level to where they were at prior to surgery. Varlamov, Benn, and Puljujarvi are examples of this. This study looked at five players who had FAI but underwent the old procedure where they would actually open up the hip joint (i.e. no small holes with a camera but a long cut to open up your hip joint so that it could be dislocated to allow the surgeon to look at it with the naked eye) and 3 returned to a similar level and 2 returned to play but at a lower level of hockey. 

We know Francouz underwent some sort of procedure this past off-season also and so it’s possible that he had the other hip operated on but that is purely speculative. I mention this because Francouz may have already had both hips operated on and not need another surgery down the line. Although the recovery is long and surgery is never a small deal, I do feel that Francouz can return to where he was last season and continue to develop into a potential starting goaltender without concern for lingering hip problems.