Origin of the direct and reflected head of the rectus femoris: an anatomic study

Evaluation of 3D Footprint Morphology of Knee-Related Muscle Attachments Based on CT Data Reconstruction: A Feasibility Study

A three-dimensional (3D) understanding of muscle attachment footprints became increasingly relevant for musculoskeletal modeling. The established method to project attachments as points ignores patient-specific individuality. Research focuses on investigating certain muscle groups rather than comprehensively studying all muscles spanning a joint. Therefore, we present a reliable method to study several muscle attachments in order to reconstruct the attachment sites in 3D based on CT imaging for future applications in musculoskeletal modeling. For the present feasibility study, 23 knee-related muscle attachments were CT-scanned postmortem from four nonadipose male specimens. For this, the specific muscle attachments were dissected and marked with a barium sulfate containing paint (60 g BaSO4 in 30 mL water and 10 mL acrylic paint). Subsequently, bone geometries and muscle attachments were reconstructed and evaluated from CT datasets. Bone morphology and footprint variations were studied. Exemplarily, variations were high for pes anserinus insertions (mean 56%) and the origins of M. biceps femoris (mean 54%). In contrast, the origins of the vastus muscles as well as the insertion of the Achilles tendon showed low variation (mean 9% and 13%, respectively). Most attachment sites showed variation exceeding the individuality of bone morphology. In summary, the present data were consistent with the few published studies of specific muscle footprints. Our data shed light on the high variability of muscle attachments, which need to be addressed when studying muscle forces and movements through musculoskeletal modeling. This is the first step to achieving a more profound understanding of muscle morphology to be utilized in numerical simulations.

Groin Pain Syndrome Italian Consensus Conference update 2023

Groin pain syndrome (GPS) is a controversial topic in Sports Medicine. The GPS Italian Consensus Conference on terminology, clinical evaluation and imaging assessment of groin pain in athletes was organized by the Italian Society of Arthroscopy in Milan, on 5 February 2016. In this Consensus Conference (CC) GPS etiology was divided into 11 different categories for a total of 63 pathologies. The GPS Italian Consensus Conference update 2023 is an update of the 2016 CC. The CC was based on a sequential, two-round online Delphi survey, followed by a final CC in the presence of all panelists. The panel was composed of 55 experts from different scientific and clinical backgrounds. Each expert discussed 6 different documents, one of which regarded the clinical and imaging definition of sports hernias, and the other 5 dealt with 5 new clinical situations thought to result in GPS. The panelists came to an agreement on the definition of a sports hernia. Furthermore, an agreement was reached, recognizing 4 of the 5 possible proposed pathologies as causes to GPS. On the contrary, the sixth pathology discussed did not find consensus given the insufficient evidence in the available scientific literature. The final document includes a new clinical and imaging definition of sports hernia. Furthermore, the etiology of GPS was updated compared to the previous CC of 2016. The new taxonomic classification includes 12 categories (versus 11 in the previous CC) and 67 pathologies (versus 63 in the previous CC).

Comparable Injury to the Indirect Head of the Rectus Femoris During Interportal and Periportal Capsulotomy: A Cadaveric Study

Background

There is concern for maintaining the integrity of the reflected head of the rectus femoris during arthroscopic hip joint access. Because of the proximity to the indirect head of the rectus femoris (IHRF), capsulotomy technique and capsular closure during routine hip arthroscopy may play a role in postoperative tendinitis.

Purpose

To quantify the extent of injury sustained to the IHRF during interportal versus periportal capsulotomy for routine arthroscopic hip joint access.

Study Design

Controlled laboratory study.

Methods

A cadaveric study was conducted using 20 fresh-frozen cadaveric hips, in which hip joint access through a periportal capsulotomy (n = 10) or interportal capsulotomy (n = 10) was performed. Capsular closure followed by a layered dissection to the capsuloligamentous complex of the hip joint was then performed to localize the IHRF. Suture proximity to the tendon, tendon disruption, and the IHRF footprint was documented to the nearest 0.01 mm using digital calipers. Statistical analysis was performed using unpaired Student t tests.

Results

The mean capsulotomy length for the interportal specimens was 19.27 ± 3.25 mm, and the mean medial and lateral capsulotomy length for the periportal specimens was 4.47 ± 1.60 and 4.26 ± 0.89 mm, respectively. There was violation of the tendon in 3 of 10 interportal specimens and 4 of 10 periportal specimens. There was no significant difference in the closest suture measured to the IHRF for specimens with versus without tendon violation, for either interportal or periportal capsulotomy.

Conclusion

We found comparable outcomes with regard to violation of the IHRF between interportal and periportal capsulotomy, with no significant difference in suture proximity to the IHRF in specimens with or without tendon violation. There remains no consensus on the ideal method by which to avoid iatrogenic damage to the IHRF.

Clinical Relevance

Our findings provide insight that may lead to future advances in surgical care, such that protection of the tendon during routine hip arthroscopy may allow for improved postoperative rehabilitation and strength.

Measuring direct and indirect tendon parameters to characterize the proximal tendinous complex of the rectus femoris in football and futsal players

Objective: To present unprecedented radiological parameters that characterize the angle between the direct and indirect tendons of the proximal rectus femoris (RF) and its inclinations and to evaluate the population variability according to demographic variables. Materials and methods: From September 2019 to July 2021, using MRI multiplanar reconstructions of the proximal thigh/hip, two blinded radiologists measured the direct and indirect tendon angle and the inclination of each tendon in different planes. The intra- and inter-observer agreements were assessed with Bland-Altman analysis and intraclass correlation coefficient (ICC). The correlations between radiological parameters and demographic variables were evaluated using linear regression, Student's t-test, and analysis of variance. Results: We performed 112 thigh/hip MRI scans on 91 football players of different age, gender, and disciplines (football and futsal). For observer 1 (the reference), the mean direct and indirect tendon angle was 56.74° ± 9.37, the mean indirect tendon slope was -7.90° ± 7.49, and the mean direct tendon slope was 22.16° ± 5.88. The three measurements showed inter- and intra-observer agreement (mean differences ∼0). No correlation was observed between age and the parameters. Likewise, no statistically significant differences were found for gender, dominant limb, examined limb, and sport. Conclusion: There is an inter- and intra-observer agreement in the measurements of the direct and indirect tendon angle and the inclination of each tendon. There is population variability in the proximal tendinous complex unrelated to demographic factors. These results allow further detection of morphological patterns that represent a risk factor for lesions in the RF in professional football and futsal players and other sports.

Relationship between anatomical injury site of rectus femoris muscle strain and time taken to return to play in Japanese professional soccer players

PURPOSE

The rectus femoris has three myotendinous or myoaponeurosis junctions and causes three types of muscle strain anatomically. We aimed to investigate the anatomical injury site of the rectus femoris muscle strain in professional soccer players as well as the characteristic findings on magnetic resonance imaging (MRI) and to evaluate its relationship with the time taken to return to play at competition levels.

METHODS

Thirteen Japanese professional soccer players who sustained injuries to the rectus femoris were included in this study. The mechanism of injury, anatomical injury site, severity, absence of hematomas, and time taken to return to competition were evaluated.

RESULTS

Ten patients were injured while kicking and three while sprinting. The anatomical injury site was the origin aponeurosis in two cases, intramuscular tendon in eight cases, and distal aponeurosis in three cases. The severity was one-degree in three cases and two-degree in 10 cases. Hematomas were observed in five cases. Cases with injuries caused by sprinting, two-degree injuries, or clear hematomas were associated with significantly longer periods of return to play than the other cases. Additionally, patients with distal aponeurosis-type injuries tended to take a long time to return to the competition.

CONCLUSIONS

In rectus femoris muscle strain, it is important to evaluate the anatomical injury site, severity, and absence of hematomas on MRI. Not only the injury mechanism, a clear hematoma, and high severity but also distal aponeurosis injuries may be associated with long periods of return to play at competition levels.

The capsular head of the proximal rectus femoris muscle: a review of the imaging anatomy of proximal muscle injury in professional athletes – early experience

The detailed anatomy of the rectus femoris and corresponding injury appearances were first described in 1995. Since then, there has been little published to change our understanding of this complex anatomical area. More recent anatomical dissection work in 2004 and 2006 alluded to the presence of an altered configuration of the proximal tendon anatomy. Whilst widely accepted that the proximal rectus femoris muscle has two distinct tendon slips, the authors in 2006 described a third separate tendon slip arising from the anterior femoral capsule and this has been widely termed the ‘capsular head’. We provide evidence that imaging features corroborate this revised anatomical concept. Whilst the clinical relevance of these findings is yet to be established, it remains important that our understanding of the radiological anatomy in this area advances with the forward growth of imaging clarity. In this review, we revisit anatomical concepts and present atypical injury cases that may be explained by the presence of a separate capsular head.

Magnetic Resonance Imaging Is Not Reliable in Classifying Anterior Inferior Iliac Spine Morphology Compared to 3-Dimensional Computerized Tomography

PURPOSE

The purpose of this study is to determine the reliability of standard magnetic resonance imaging (MRI) evaluation of AIIS morphology compared with three-dimensional (3D) computerized tomography (CT) (reference standard).

METHODS

Sixty hips in 30 patients met the inclusion criteria. The images were reviewed and classified by two fellowship-trained orthopedic surgeons. A second imaging viewing session was conducted in the same manner for validation of AIIS evaluation. The agreement and accuracy indices between the two raters were calculated for each imaging modality (inter-rater agreement) as well the agreement across the imaging modality for each rater (intermethod agreement).

RESULTS

The inter-rater agreement for the morphological evaluation of the AIIS for the first session according to 3D CT was .553 (P < .05) and by means of MRI was .0163 (P < .05). The inter-rater agreement for the second session by means of 3D CT was .449 (P < .05) and according to MRI was 0 (P < .05). The inter-method agreement for rater 1 for the first session was .04 (P < 0.05), while the agreement for rater 2 was .016 (P < .05). The intermethod agreement for rater 1 on the second session was .35 (P < 0.05), while that of rater 2 was .297(P < .05). The overall accuracy of MRI compared to 3D CT for rater 1 for the first session was .531, .490, and .959 for types I, II, III respectively and .551, .531, and .980 for the second session for types I, II, and III respectively. The overall accuracy of MRI compared to 3D CT for rater 2 for the first session was .551, .469, and .918 for types I, II, III respectively and .633, .592, and .918 for the second session for types I, II, and III, respectively.

CONCLUSION

MRI evaluations and subsequent classifications of AIIS morphology demonstrated a poor to slight correlation compared with that of the reference standard of 3D CT.

LEVEL OF EVIDENCE

Level II, retrospective diagnostic study.

Arthroscopic and Endoscopic Treatment of Proximal Rectus Femoris Avulsion

Proximal rectus femoris avulsion (PRFA) is an uncommon injury that is poorly reported in the literature. Historically, these injuries have been treated nonoperatively or with open techniques. This is the first study showing endoscopic treatment of this injury. We present a systematic review of PRFA treatment and a case report of a patient whose injury was treated endoscopically. Sixty-four injuries were reported across several sports. Patients underwent nonoperative management, suture repair, suture anchor repair, or excision of the tendon stump. Surgical complications included lateral femoral cutaneous nerve injury and wound complications. The patient who underwent arthroscopic treatment had a good outcome. [Orthopedics. 2022;45(1):e1-e6.].

Arthroscopic Management of Subspinous Impingement in Borderline Hip Dysplasia and Outcomes Compared With a Matched Cohort With Nondysplastic Femoroacetabular Impingement

BACKGROUND

Arthroscopic management of femoroacetabular impingement (FAI) in the setting of borderline hip dysplasia is controversial. Recently, there has been increased awareness of a prominent anterior inferior iliac spine (AIIS) resulting in subspinous impingement.

PURPOSE/HYPOTHESIS

The purpose was to report outcomes of arthroscopic subspinous decompression in patients with symptomatic hip impingement and borderline hip dysplasia compared with a matched cohort with nondysplastic FAI. Addressing a prominent subspinous region and cam/pincer lesion in the borderline dysplastic hip may lead to favorable outcomes comparable with those of patients undergoing arthroscopic management of nondysplastic FAI.

STUDY DESIGN

Cohort study; Level of evidence, 3.

METHODS

Patients with symptomatic hip impingement, borderline dysplasia (lateral center-edge angle [LCEA], 18°-24°), and prominent AIIS (BDSI group) whose nonoperative management failed and who subsequently underwent arthroscopic subspinous decompression were retrospectively identified. Three-dimensional computed tomography imaging was used to categorize AIIS morphology into type 1, 2, or 3 (Hetsroni classification). Patient-reported outcome (PRO) scores consisting of the modified Harris Hip Score (mHHS), Hip Outcome Score-Activities of Daily Living (HOS-ADL), and Hip Outcome Score-Sport-Specific Subscale (HOS-SSS) were obtained preoperatively and at an average of 44 months postoperatively (range, 23-61 months). Exclusion criteria were Tönnis osteoarthritis grade >1 and a history of previous hip procedures. An age-, sex-, and body mass index-matched cohort of patients without dysplasia (LCEA, >25°) who underwent arthroscopic FAI surgery with a minimum 2-year follow-up were selected to serve as the control group.

RESULTS

Eighteen patients, 19 hips (14 women and 4 men; average age, 28 years) were included. Of the 19 hips in the BDSI group, the average LCEA and alpha angle were 21.8° and 66.2°, respectively; 14 hips were Hestroni type 2, and 5 hips were type 1. There were no postoperative complications or additional procedures performed since the last follow-up. Repeated-measures analysis of variance revealed a significant improvement in all PRO scores from preoperatively to the last follow-up: mHHS, 64.7 to 87.7 (P < .001); HOS-ADL, 62.1 to 92.1 (P < .001); HOS-SSS, 26.5 to 87.1 (P < .001). An analysis of covariance revealed that patients with type 2 AIIS had a significantly higher postoperative mHHS than those with a type 1 morphology (88.3 and 95.6, respectively; P < .01) The BDSI group had a significantly lower preoperative HOS-SSS (26.5; P < .001) in comparison with the control group. However, there was no significant difference in postoperative outcome scores between groups. The BDSI group underwent significantly more microfracture, capsular plication, and ligamentum teres debridement (15.8%; P = .04).

CONCLUSION

Arthroscopic AIIS decompression in patients with coexisting borderline dysplasia and subspinous impingement is a safe and effective method of treatment that produces outcomes comparable with those of a cohort with nondysplastic FAI.

The anatomical properties of the indirect head of the rectus femoris tendon: a cadaveric study with clinical significance for labral reconstruction surgery

BACKGROUND

Acetabular labral tear is a common pathology. In some clinical situations, primary labral repair may not be possible and labral reconstruction is indicated.

PURPOSE AND CLINICAL RELEVANCE

Describe the anatomy of the indirect head of the rectus femoris (IHRF) tendon with clinical application in arthroscopic labral reconstruction surgery.

METHODS

Twenty-six cadaver hips were dissected. Thirteen measurements, each with clinical relevance to arthroscopic labral reconstruction using an IHRF tendon graft were taken on each hip. All measurements were taken in triplicate. Mean values, standard deviations and intra-observer reliability were calculated.

RESULTS

The mean footprint of the direct head of the rectus femoris tendon was 10.6 mm × 19.6 mm. The width and thickness at the confluence of both heads were 10.9 mm and 6.9 mm, respectively. The mean total length of the footprint and "free portion" of the IHRF was 55.3 mm, the mean cranial to caudal footprint measured at the 12 o'clock, 1 o'clock, and 2 o'clock positions were 22.3 mm. The mean length of the Indirect Head footprint alone was 38.1 mm. The mean length of IHRF tendon suitable for grafting was 46.1 mm and the mean number of clock face sectors covered by this graft was 3.3 clock face sectors. Intra-observer reliability was ≥ 0.90 for all recorded measurements. The origin of the IHRF on the acetabulum fans out posteriorly, becoming thinner and wider as the origin travels posteriorly. The tendon footprint is firmly attached on the lateral wall of the ilium and becomes a free tendon overlying the acetabular bone as it travels anteriorly and distally towards its muscular attachment.

CONCLUSION

The IHRF tendon is in an ideal location for harvesting and contains the appropriate thickness, length and triangular architecture to serve as a safe and local graft source for acetabular labral reconstruction surgery.

Anatomical variants of the rectus femoris motor innervation

Adult periacetabular osteotomy (PAO) was originally performed through the classic Smith-Petersen approach for optimal operative visibility and acetabular fragment correction. Evolution towards an abductor-sparing technique significantly lowered the post-operative morbidity. The rectus-sparing approach represents a step further, but the innervation of the rectus femoris is theoretically more at risk. Although the topographic anatomy of the femoral nerve has been well described, it was never studied with specificity to surgical landmarks. The femoral nerve’s spatial relation with the anterior-inferior iliac spine (AIIS) and the amount of possible dissection in the rectus femoris and iliopsoas interval is uncertain. Seven formalin-preserved human cadaveric specimens without history of inguinal injury or surgery were dissected using the distal limb of an iliofemoral approach. The level of entry of motor innervation was measured and number of branches to the rectus femoris was noted. The average longitudinal distance from the AIIS to the first motor nerve to the rectus femoris was 8.6 ± 1.4 cm. The number of branches varied between 1 and 4 with the most common innervation pattern being composed of two segments. Dissection medial to the rectus femoris should not be carried out further than 7 cm distal to the AIIS and stretching of that interval during surgical exposure should be done cautiously. The clinical efficiency of the rectus-sparing approach should be studied further in order to confirm its advantage over the classic direct anterior approach. The study provides a better understanding of the localization and the anatomical variations of the structures encountered at the level of and below the AIIS. It also assesses the relative risk of denervation of the rectus femoris during PAO through the rectus-sparing approach. The authors recommend that the dissection medial to the rectus femoris should be carried out no further than 7 cm distal to the AIIS and stretching of that interval during surgical exposure should be done cautiously.

Effects of dry needling in HIP muscles in patients with HIP osteoarthritis: A randomized controlled trial

BACKGROUND

Dry needling (DN) in active myofascial trigger points (MTrPs) is effective to reduce pain, increase range of motion (ROM) and improve physical function in different musculoskeletal disorders. However, there is a lack of studies evaluating the effects of DN in active MTrPs in hip osteoarthritis (OA).

OBJECTIVE

To determine the short-term effects of DN on pain, hip ROM and physical function in patients with hip OA.

DESIGN

Double-blind randomized controlled trial.

METHODS

Thirty patients with unilateral hip OA were randomized into two groups: DN group and sham group. Participants received three treatment sessions. The treatment was applied in active MTrPs of the iliopsoas, rectus femoris, tensor fasciae latae and gluteus minimus muscles. Pain intensity (visual analogic scale), passive hip ROM (universal goniometer and digital inclinometer) and physical function (30s chair-stand test and 20m walk test) were assessed at baseline and after the three treatment sessions.

RESULTS

There was decreased pain intensity, increased hip ROM, and improved physical function following the DN treatment. These improvements were statistically significant (p < 0.05) compared to the sham group. The sham group had increased pain intensity and decreased hip ROM (p < 0.05).

CONCLUSION

Pain, hip ROM, and physical function improved after the application of DN in active MTrPs of the hip muscles in patients with hip OA.

Calcific tendinopathy of the direct head of rectus femoris: a rare cause of groin pain treated with ultrasound guided percutaneous irrigation

Groin pain can be caused by a myriad of pathologies. Abnormalities of the rectus femoris are a very rare cause of groin pain; calcific tendinopathy of the direct head is particularly so, with only two case reports in the literature. We report the first case of calcific tendinopathy of the direct head of the rectus femoris that was treated effectively with ultrasound-guided percutaneous irrigation of calcific tendinopathy (USPICT). The anatomy of the rectus femoris and the technique for US-PICT of the rectus femoris are also described.

The prevalence of a prominent anterior inferior iliac spine

INTRODUCTION

Impingement of the prominent anterior inferior iliac spine (AIIS) against the femoral neck has recently been described as another type of impingement. The purpose of this study is to provide a distribution of AIIS types using the classification proposed by Hetsroni and thus report on the prevalence of prominent types.

MATERIALS AND METHODS

A total of 400 patients were included in the study with an average age 27.3 ± 6.9 years (range 18-40). All patients received a whole-body polytrauma computer tomography (CT) scan in the emergency room (ER) upon arrival. The classification of AIIS proposed by Hetsroni et al., which describes three morphological types, was used. Type II and III were grouped as prominent types. The measurements were performed in all three planes by two examiners.

RESULTS

Male to female ratio was 71:29. Type I was observed in 367 (91.7%) patients. Type II was observed in 31 (7.8%) patients and type III was observed in 2 (0.5%) patients, unilaterally. Prominent types were much more prevalent in men (10.5%) than in women (2.6%). The CT assessment demonstrated excellent intra- and interreliability (overall: 0.926, I/II: 0.906, III: 1.000).

CONCLUSION

A young population demonstrates a prevalence of a prominent AIIS of 11.5%. Prominent AIIS is more common in men than in women.

Imaging finding and arthroscopic treatment of isolated contracture of the rectus femoris muscle: a case report

Background

Isolated rectus femoris (RF) contracture is encountered very rarely in orthopaedic practices. There are few reports on its imaging manifestations and no cases reported to be treated with arthroscopy.

Case presentation

A 11-year-old girl with a more than 7 years history of restricted left knee flexion was presented. The clinical assessment and magnetic resonance imaging (MRI) findings were detailed here. A strip-like induration was palpated in the left thigh, which tends to be more obvious with knee flexion. MRI demonstrated a hypointensity band connected the anterior inferior iliac spine with the patella, and marked atrophy of the left RF muscle. Fibrosis contracture band was confirmed with arthroscope, then divided by radiofrequency ablation (RFA) under arthroscopic observation. Followed by debridement of the fibrillar connective tissue and hemostasis around the broken ends. The movement of left knee joint significantly improved after the operation, and the patient recovered nearly full range of motion of this joint after 6 months.

Conclusion

The specific MRI findings could assist in confirming clinical early diagnosis of isolated RF contracture. Arthroscopic RFA treatment is an effective technique to treat this disorder with minimally incision.

Electronic supplementary material

The online version of this article (10.1186/s12891-019-2696-8) contains supplementary material, which is available to authorized users.

Graft choices for acetabular labral reconstruction

The acetabular labrum plays a key role in maintaining hip function and minimizing hip degeneration. Once thought to be a rare pathology, advances in imaging have led to an increase in the number of diagnosed labral tears. While still a relatively new field, labral reconstruction surgery is an option for tears that are irreparable or require revision after primary repair. Various autograft and allograft options exist when considering labral reconstruction. The first labral reconstruction surgery was described using the ligamentum teres capitis, and has since evolved, incorporating more graft sources and reconstructive techniques. The purpose of this review is to assess and describe the different graft sources and technique currently implemented by hip surgeons. Moreover, this review attempts to determine whether a single labral reconstructive graft type is superior to the others. Techniques using the Ligamentum teres capitis autograft, ITB autograft, gracilis autograft, quadriceps tendon autograft, capsular autograft, semitendinosus allograft, indirect head of the rectus femoris autograft, peroneus brevis tendon allograft and Tensor fascia lata allograft were found. Scoring was available on 5 out of the 9 graft types. The advantages and disadvantages of each graft source is described as a comparative tool. No single graft type has shown increased benefit in acetabular labral reconstruction. The lack of uniform outcome measurements hinders comparison of reported outcomes. Surgeons should make an informed decision based on their experience as well as the patient's history and needs when choosing which graft type would be best suited for their patients.

Operative Treatment of Proximal Rectus Femoris Injuries in Professional Soccer Players: A Series of 19 Cases

Background:

Proximal rectus femoris (PRF) tears are relatively rare injuries among top-level athletes. PRF injuries can be avulsions of both tendon heads (direct and reflected heads) or of a single head, and some have a tendency to progress to recurrent injuries.

Purpose:

To describe a series of operatively treated PRF ruptures in professional soccer players.

Study Design:

Case series; Level of evidence, 4.

Methods:

Nineteen cases of PRF injuries (18 patients, 1 bilateral) in professional soccer players who were treated surgically were retrospectively reviewed. Perioperative findings with return-to-play data were recorded.

Results:

Of the PRF injuries, 10 total avulsions (both heads) and 9 single-head tears were seen on magnetic resonance imaging and were later confirmed during surgery. All 18 patients returned to their preinjury level of play (mean follow-up, 2.8 years [range, 1-11 years]).

Conclusion:

The repair of PRF tears in professional soccer players yielded good results and allowed all patients to return to their preinjury level of play.

Acetabular labral reconstruction using the indirect head of the rectus femoris tendon significantly improves patient reported outcomes

PURPOSE AND HYPOTHESIS

The aim of this study was to evaluate outcomes after acetabular labral reconstruction using the indirect head of the rectus femoris tendon. The study hypothesis stated that arthroscopic acetabular labral reconstruction may improve patient reported outcomes in patients with labral tears that were not amenable to repair.

METHODS

Between 2009 and 2015, the senior author performed 31 acetabular labral reconstructions using the indirect head of the rectus femoris tendon. The graft is harvested through the same arthroscopic portals established for the procedure. The graft was gradually secured to the acetabular rim starting at its origin to the myotendinous junction, reestablishing the suction seal of the joint. Medical records and surgical reports were reviewed for demographic data, and outcome measures were assessed with pre- and postoperative modified Harris Hip Scores (mHHS).

RESULTS

Twenty-two patients with follow-up of more than 2 years were evaluated. Fourteen procedures were revision hip arthroscopy and 8 were primary labral reconstruction in 13 males and 9 females. The median age was 43 (range 22-68 years old). The median follow-up time was 36.2 months with a range from 24 to 72 months. The median preoperative mHHS was 67.1. Postoperatively, patients improved to a median mHHS of 97.8 (range 73.7-100) (p < 0.0001).

CONCLUSION

Acetabular labral reconstruction using the indirect head of the rectus femoris tendon is a minimally invasive surgical procedure. The technique was applicable in all patients in this study with good outcomes. This procedure is clinically relevant for patients with large labral tears not amendable to labral repair as it offers good results using a local allograft. The local allograft is clinically advantageous as there is no additional donor-site morbidity and no risk of disease transmission.

LEVEL OF EVIDENCE

IV.

Sonographic Overview of Usual and Unusual Disorders of the Rectus Femoris Tendon Origins

Rectus femoris muscle proximal injuries are not rare conditions. The proximal rectus femoris tendinous anatomy is complex and may be affected by traumatic, microtraumatic, or nontraumatic disorders. A good knowledge of the proximal rectus femoris anatomy allows a better understanding of injury and disorder patterns. A new sonographic lateral approach was recently described to assess the indirect head of the proximal rectus femoris, hence allowing for a complete sonographic assessment of the proximal rectus femoris tendons. This article will review sonographic features of direct, indirect, and conjoined rectus femoris tendon disorders.

[Arthroscopic decompression of extra-articular subspinal hip impingement]

OBJECTIVE

Complete arthroscopic decompression of the impinging subspinal soft tissues and resection of the hypertrophic bone formation between the anterior hip capsule and the anterior inferior iliac spine (AIIS) or decompression of a hypertrophic AIIS.

INDICATIONS

Painful anterior hip impingement and decreased hip flexion following a hypertrophic osseous subspinal deformation.

CONTRAINDICATIONS

No clinical symptoms or decreased anterior hip function despite radiological osseous subspinal hip impingement.

SURGICAL TECHNIQUE

Hip arthroscopy in supine position on an extension table. Treatment of possible intraarticular hip pathologies in the central or peripheral compartment. Arthroscopic visualization of the hypertrophic impinging soft tissues below the AIIS and decompression using a shaver or radiofrequency device. Complete arthroscopic resection of the hypertrophic AIIS parts and the osseous subspinal deformation using a high speed burr under fluoroscopic control.

POSTOPERATIVE MANAGEMENT

Early functional rehabilitation with full weight-bearing and unlimited hip motion; 3 weeks ossification prophylaxis and 8 weeks of limitation for jumping and running sports activities.

RESULTS

There are no comparative studies or medium- and long-term study results in the literature for arthroscopic AIIS decompression. However, currently published case series show an improvement of the determined scores.

Hip and Groin Injuries in Baseball Players

PURPOSE OF REVIEW

To discuss the clinical significance of the most common hip and groin injuries in baseball players, as well as an algorithmic approach to diagnosis and treatment of these injuries.

RECENT FINDINGS

(a) Limitations in throwing velocity, pitch control, and bat swing speed may be secondary to decreased mobility and strength within the proximal kinetic chain, which must harness power from the lower extremities and core. (b) Approximately 5.5% of all baseball injuries per year involve the hip/groin and may lead to a significant amount of time spent on the disabled list. Injuries involving the hip and groin are relatively common in baseball players. Our knowledge of the mechanics of overhead throwing continues to evolve, as does our understanding of the contribution of power from the lower extremities and core. It is paramount that the team physician be able to accurately diagnose and treat injuries involving the hip/groin, as they may lead to significant disability and inability to return to elite levels of play. This review focuses on hip- and groin-related injuries in the baseball player, including femoroacetabular impingement, core muscle injury, and osteitis pubis.

Arthroscopic Focal Subspinal Decompression and Management of Pincer-Type Femoroacetabular Impingement

Femoroacetabular impingement syndrome is a common hip pathology significantly affecting not only the intra- and extra-articular structures but also the biomechanical function of the joint. Cam and pincer bony lesions have been extensively studied. However, during recent years, other types of extra-articular impingement between the pelvic and femoral bone have been investigated. When a prominent or morphologically abnormal anterior-inferior iliac spine (AIIS) impinges repetitively on the femoral side during motion, the subspinal acetabular region becomes prominent and extends toward the intra-articular part of the joint. This results in restriction of the range of motion of the hip and pain, especially with flexion. Therefore, during hip arthroscopy, it is necessary to evaluate the subspinal region (triangular area located at 1:30 to 2:30 o'clock using the acetabular clock face system). For the correction of the acetabular bone pathology to be complete, the surgeon should focus both on the pincer and subspinal impingement lesions. This article describes our preferred technique to successfully address subspinal and pincer acetabular impingement during hip arthroscopy. The pearls and pitfalls of this technique are discussed.

Current concepts in the diagnosis and management of extra-articular hip impingement syndromes

PURPOSE

Extra-articular hip impingement syndromes encompass a group of conditions that have previously been an unrecognised source of pain in the hip and on occasion been associated with intra-articular hip impingement as well. As arthroscopic techniques for the hip continue to evolve, the importance of these conditions has been recognised recently and now form an important part of the differential of an individual presenting with hip pain. The aim of this article, therefore, is to provide the reader with an evidence-based and comprehensive update of these syndromes.

METHODS

By reviewing past literature, the anatomy, pathophysiology, clinical features and the management of the five common extra-articular hip impingement syndromes were described.

RESULTS

The common extra-articular impingement syndromes are: 1) Ischiofemoral impingement: quadratus femoris muscle becomes compressed between the lesser trochanter and the ischial tuberosity. 2) Subspine impingement: mechanical conflict occurs between an enlarged or malorientated anterior inferior iliac spine and the distal anterior femoral neck. 3) Iliopsoas impingement: mechanical conflict occurs between the iliopsoas muscle and the labrum, resulting in distinct anterior labral pathology. 4) Deep gluteal syndrome: pain occurs in the buttock due to the entrapment of the sciatic nerve in the deep gluteal space. 5) Pectineofoveal impingement: pain occurs when the medial synovial fold impinges against overlying soft tissue, primarily the zona orbicularis. Knowledge for these syndromes still remains limited for reasons mostly relating to their low prevalence and their co-existence with typical femoro-acetabular impingement.

CONCLUSIONS

The knowledge of extra-articular hip impingement syndromes is essential and should form a part of the differential diagnoses alongside intra-articular pathology including femoro-acetabular impingement particularly in the younger patient with a non-arthritic hip.

Morphological Distribution of the Anterior Inferior Iliac Spine in Patients With and Without Hip Impingement: Reliability, Validity, and Relationship to the Intraoperative Assessment

BACKGROUND

Subspinous impingement of the anterior inferior iliac spine (AIIS) on the femoral head-neck junction is increasingly recognized as a source of hip impingement. A classification system of AIIS morphology has previously been proposed that correlates with reduced hip motion and may predispose patients to subspinous hip impingement.

PURPOSE

To examine the morphological distribution of AIIS types in patients with and without diagnosed hip impingement and correlate AIIS morphology to intraoperative findings at the time of surgery.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

Three-dimensional reconstructed pelvic computed tomography scans were generated for a stratified sample of 449 hips in patients without a history of hip pain or hip impingement and 59 hips in patients with a diagnosis of hip impingement. Three blinded assessors classified the AIIS for each hip twice. The morphological distribution between symptomatic and asymptomatic patients was compared, controlling for age, sex, and affected side. Within the symptomatic cohort, AIIS morphology was compared with the intraoperative assessment of a low-lying AIIS using the Fisher exact test.

RESULTS

The intraobserver reliability of the classification system in our cohort was substantial (κ = 0.68-0.77). The interobserver reliability was moderate (κ = 0.50). The morphological distribution between symptomatic and asymptomatic patients was similar, with 75% of patients in the asymptomatic group and 80% of the patients in the symptomatic group having a type 2 or type 3 AIIS. When matched for age, sex, and affected side, there was no significant difference in the assessed classification type between the groups ( P = .55). Within the symptomatic group, there was no significant correlation between the surgeon assessment of a low-lying AIIS and a type 2 or type 3 radiographic classification ( P = .10). The positive predictive value of a type 2 or type 3 AIIS classification for hip impingement symptoms was 10%, and the negative predictive value was 91%.

CONCLUSION

These findings suggest that a high percentage of patients with AIIS morphology associated with subspinous impingement are, in fact, asymptomatic. The current radiographic classification scheme should not be used exclusively for clinical decision making.

Arthroscopic hip preservation surgery practice patterns: an international survey

To design and conduct a survey analyzing pre-, intra- and post- hip arthroscopy practice patterns among hip arthroscopists worldwide. A 21-question, IRB-exempt, HIPAA-compliant, cross-sectional survey was conducted via email using SurveyMonkey to examine pre-operative evaluation, intra-operative techniques and post-operative management. The survey was administered internationally to 151 hip arthroscopists identified from publicly available sources. Seventy-five respondents completed the survey (151 ± 116 hip arthroscopy procedures per year; 8.6 ± 7.1 years hip arthroscopy experience). Standing AP pelvis, false profile and Dunn 45 were the most common radiographs utilized. CT scans were utilized by 54% of surgeons at least some of the time. Only 56% of participants recommended an arthrogram with MRI. Nearly all surgeons either never (40%) or infrequently (58%) performed arthroscopy in Tönnis grade-2 or grade-3 osteoarthritis. Surgeons rarely performed hip arthroscopy on patients with dysplasia (51% never; 44% infrequently). Only 25% of participants perform a routine 'T' capsulotomy and 41% close the capsule if the patient is at risk for post-operative instability. Post-operatively, 52% never use a brace, 39% never use a continuous passive motion, 11% never recommended heterotopic ossification prophylaxis and 30% never recommended formal thromboembolic disease prophylaxis. Among a large number of high-volume experienced hip arthroscopists worldwide, pre-, intra- and post- hip arthroscopy practice patterns have been established and reported. Within this cohort of respondents, several areas of patient evaluation and management remain discordant and controversial without universal agreement. Future research should move beyond expert opinion level V evidence towards high-quality appropriately designed and conducted investigations.

Anterior Inferior Iliac Spine (AIIS) and Subspine Hip Impingement

BACKGROUND

Abnormal morphology of the anterior inferior iliac spine (AIIS) and the subspine region of the acetabular rim are increasingly being recognised as a source of symptomatic extra-articular hip impingement. This review article aims to highlight important differences in the pathogenesis, clinical presentation and management of extra-articular hip impingement from both the AIIS and subspine bony regions, and the outcome following surgical intervention.

METHODS

A literature review was undertaken to examine the supporting evidence for AIIS and subspine hip impingement. A narrative account of the Author's professional experience in this area, including operative technique for arthroscopic correction, is also presented.

RESULTS

Abnormal morphology of the AIIS and subspine region has been classified using cadaveric, radiological and arthroscopic means; the clinical presentation and operative treatment has been documented in several case series studies. Dual pathology is often present - recognition and treatment of both intra- and extra-articular components are necessary for good postoperative outcome.

CONCLUSIONS

AIIS and sub-spine hip impingement should be considered as distinct pathological entities, which may also co-exist. Symptom relief can be expected following arthroscopic deformity correction with the treatment of concomitant intra-articular pathology. Failure to recognise and treat the extra-articular component may affect postoperative outcome.

LEVEL OF EVIDENCE

V.

Imaging of rectus femoris proximal tendinopathies

The rectus femoris is the most commonly injured muscle of the anterior thigh among athletes, especially soccer players. Although the injury pattern of the muscle belly is well documented, less is known about the anatomy and specific lesions of the proximal tendons. For each head, three distinctive patterns may be encountered according to the location of the injury, which can be at the enthesis, within the tendon, or at the musculotendinous junction. In children, injuries correspond most commonly to avulsion of the anteroinferior iliac spine from the direct head and can lead to subspine impingement. Calcific tendinitis and traumatic tears may be encountered in adults. Recent studies have shown that traumatic injuries of the indirect head may be underdiagnosed and that injuries of both heads may have a surgical issue. Finally, in the case of tears, functional outcome and treatment may vary if the rupture involves one or both tendons and if the tear is partial or complete. Thus, it is mandatory for the radiologist to know the different ultrasound and magnetic resonance imaging (MRI) patterns of these lesions in order to provide accurate diagnosis and treatment. The purpose of this article is to recall the anatomy of the two heads of rectus femoris, describe a reliable method of assessment with ultrasound and MRI and know the main injury patterns, through our own experience and literature review.

Radiographic Identification of Arthroscopically Relevant Acetabular Structures

BACKGROUND

The anatomy of the acetabulum has been described extensively in the literature, but radiographic acetabular guidelines have not been well established. This study provides a radiographic map of acetabular landmarks in the hip.

PURPOSE/HYPOTHESIS

The purpose of this study was to quantify the precise radiographic location of arthroscopic landmarks around the acetabulum. The hypothesis was that their locations were reproducible despite variability in the anatomy and positioning of pelvic specimens.

STUDY DESIGN

Descriptive laboratory study.

METHODS

Ten fresh-frozen cadaveric specimens were dissected, and radio-opaque hardware was placed for each landmark of interest. Anteroposterior (AP) and false-profile radiographs were obtained, and measurements were taken using a digital picture archiving and communication system.

RESULTS

On AP radiographs, the direct and indirect heads of the rectus femoris were a mean 48.2 ± 4.6 mm and 44.7 ± 4.3 mm proximal to the teardrop line, respectively. The mean radiographic distance between their insertions was 5.0 ± 3.4 mm. Moreover, the anterior inferior iliac spine was a mean 11.5 ± 3.8 mm from the acetabular rim. On false-profile radiographs, the mean distance between the direct and indirect heads of the rectus femoris was 31.4 ± 6.2 mm. The mean distance between the superior margin of the anterior labral sulcus (the psoas-u) and the midpoint of the transverse acetabular ligament was 41.0 ± 5.7 mm. Additionally, the direct and indirect heads of the rectus femoris corresponded to the 2:30 and 1:30 locations on the acetabular clockface, respectively. The midpoint of the transverse acetabular ligament was located at 7 o'clock on the clockface.

CONCLUSION

The most important finding of this study, determined by quantitative measurements, was that the described surgical landmarks had reliable locations on radiographs. Distances between landmarks as well as distances between landmarks and reference lines were reproducible in both AP and false-profile views.

CLINICAL RELEVANCE

An understanding of how acetabular structures present on radiographs could lead to more accurate portal and hardware placement intraoperatively during arthroscopic surgery as well as better preoperative and postoperative assessments.

Avulsion of the direct head of rectus femoris following arthroscopic subspine impingement resection: a case report

Arthroscopic resection of the anterior inferior iliac spine (AIIS) for subspine impingement has become a relatively common procedure. The AIIS is the origin of the direct head of rectus femoris (dhRF). Previous studies have reported that removal of the contributing portion of the AIIS causing impingement is unlikely to weaken the attachment of the dhRF. The purpose of this article is to report a case of avulsion of the dhRF, following revision hip arthroscopy for the treatment of subspine impingement. A 23-year-old professional footballer underwent revision left hip arthroscopy for the treatment of subspine impingement. 5-mm of bone was resected inferior to the AIIS. Two-weeks post-operatively, he presented with sudden onset, severe left anterior thigh pain following a fall and hyperextension of his left hip. The patient felt a pop over the anterior aspect of his hip. He noticed immediate swelling, severe pain and stiffness. Examination revealed diffuse swelling, 4/5-power on straight-leg-raise, focal tenderness over the AIIS but no palpable gap. MRI confirmed the clinical suspicion of a dhRF avulsion. Given the minimal loss of power and the lack of significant retraction, the patient was treated conservatively. He was instructed to avoid excessive hip extension. He returned to full participation at 3-months. This article highlights a case of avulsion of the dhRF due to a hyperextension injury of the hip following arthroscopic resection of subspinal impingement, a previously unreported complication. Resection of soft and bone from the AIIS may weaken the insertion of the dhRF. Care should be taken during post-operative rehabilitation to avoid trauma and excessive forces on the dhRF tendon, which may lead to rupture. Rehabilitation should be focused on range of motion of the hip.

Effect of Subspine Decompression on Rectus Femoris Integrity and Iliopsoas Excursion: A Cadaveric Study

PURPOSE

To determine the relative influence of anteroinferior iliac spine (AIIS) or subspine decompression on proximal rectus femoris integrity and iliopsoas excursion throughout a physiological range of motion.

METHODS

Nineteen cadaveric hips from 10 specimens were dissected to retain the origin of the rectus femoris direct and indirect heads. The anatomic footprints of the origins were measured with calipers. Serial 5-mm resections of the AIIS were made to determine the extent of proximal tendon disruption that corresponded to each resection. Iliopsoas tendon tracking was also assessed after sequential AIIS decompression by measuring the excursion of the medial border of the iliopsoas tendon as it traveled from its native resting position to the point where it first encountered bony impingement at the AIIS.

RESULTS

The mean proximal-distal footprint of the rectus femoris direct head was 17.95 ± 2.99 mm. The mean medial-lateral distance was 11.84 ± 2.34 mm. There was a consistent bare area along the inferior aspect of the AIIS that averaged 4.84 ± 1.42 mm. The average percentage of remaining footprint after each 5-mm resection (5 to 25 mm) was 96%, 65%, 35%, 14%, and 11%, respectively, with statistical significance noted after resections larger than 5 mm (P < .001). The native excursion distance of the iliopsoas tendon was 14.05 mm. With each 5-mm resection, the percentage of excursion before impingement on the AIIS increased by 18%, 45%, 72%, 95%, and 100%, respectively, which was statistically significance after all resections (P < .001).

CONCLUSIONS

Our study maps the anatomic footprint of the direct head of the rectus femoris tendon and confirms a previously identified bare area along the inferior aspect of the AIIS. Female cadaveric hips had a significantly smaller rectus footprint than male cadavers in our study (P < .001). Subspine decompression greater than 10 mm significantly compromises the rectus femoris origin and should be avoided when performing arthroscopic AIIS decompression. In addition, subspine decompression significantly improves tracking of the iliopsoas tendon throughout a physiological range of motion and may be considered a surgical adjunct when treating symptomatic iliopsoas snapping.

CLINICAL RELEVANCE

Arthroscopic subspine decompression serves as an important treatment modality for AIIS impingement. With a more thorough understanding of AIIS anatomy, subspine decompression can be used to relieve impingement symptoms and possibly improve iliopsoas tracking while safely maintaining rectus femoris footprint integrity.

Hip impingement: beyond femoroacetabular

In the last 20 years, femoroacetabular impingement has been at the forefront of clinical practice as a cause of hip pain in young adults. As arthroscopic techniques for the hip continue to evolve, the possible presence of a new group of conditions creating mechanical conflict in and around the hip joint (ischiofemoral, subspine and iliopsoas impingement) has recently been elucidated whilst interest in already known 'impingement' syndromes (pelvic-trochanteric and pectineofoveal impingement) is now revived. This article attempts to increase awareness of these relatively uncommon clinical entities by describing their pathomorphology, contact mechanics, treatment and published results available to present. It is hoped that such knowledge will diversify therapeutic options for the clinician, thereby improving outcomes in a small but not negligible portion of patients with previously unexplained persistent symptoms.

An anatomical study of the indirect tendon of the rectus femoris using ultrasonography

The aim of this study was to demonstrate that ultrasound can allow a precise assessment of the indirect tendon of the rectus femoris using a new lateral approach.

METHODS AND MATERIALS

Four hips were dissected for the anatomical study of the proximal rectus femoris insertions. Under ultrasonographic guidance, spinal needles piercing the direct tendon were placed in the indirect tendon, following by dissection. Then, high-resolution ultrasound was performed in 20 volunteers with assessment of the indirect tendon of the rectus femoris.

RESULTS

At dissection, the spinal needles were located in or immediately adjacent to the indirect tendon, thus confirming that it was correctly depicted by ultrasound. The indirect tendon could be identified in each cadaver and each volunteer with ultrasound. The optimal position of the probe to allow assessment of the indirect tendon could be defined. No significant changes in the appearance or thickness of the tendon could be observed.

CONCLUSION

The results of our study showed that the indirect tendon of the rectus femoris muscle can be clearly depicted by sonography in healthy adult subjects. The potential applications of this new use of sonography must now be confirmed by clinical studies.

KEY POINTS

• The anatomy of the proximal rectus femoris is reviewed • Until now, sonography was limited for assessing direct and conjoined tendons • The indirect tendon can be clearly depicted by sonography • A new lateral approach for studying the indirect tendon is described.