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

Outcomes of Arthroscopic Decompression of the Anterior Inferior Iliac Spine: A Systematic Review and Meta-analysis

BACKGROUND

Anterior inferior iliac spine (AIIS) impingement has been increasingly recognized as a source of extra-articular impingement and hip pain. However, no aggregate data analysis of patient outcomes after AIIS decompression has been performed.

PURPOSE

To evaluate outcomes after arthroscopic AIIS decompression.

STUDY DESIGN

Meta-analysis; Level of evidence, 4.

METHODS

A systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. PubMed, EMBASE, and Cochrane Central Register of Controlled Trials were queried for all English-language studies reporting outcomes of arthroscopic AIIS decompression performed in isolation or in conjunction with hip impingement correction surgery. After screening, 10 articles were included. The indications for AIIS decompression were recorded, and weighted mean improvements in patient-reported outcome (PRO) scores, complication rates, and revision rates were calculated.

RESULTS

A total of 547 patients (311 women; 57%) were identified, with a total of 620 operative hips. The mean age was 28.42 ± 5.6 years, and the mean follow-up was 25.22 ± 11.1 months. A total of 529 hips (85%) underwent AIIS decompression, 530 hips (85%) underwent femoral osteochondroplasty, and 458 hips (74%) underwent labral repair. Of the patients, 13% underwent bilateral AIIS decompression. The mean modified Harris Hip Score improved from 61.3 ± 6.9 to 88.7 ± 4.7 postoperatively (change, 27.4 ± 5.7 points; P < .001), the Hip Outcome Score-Activities of Daily Living improved from 67.2 ± 10.6 to 91.1 ± 3.2 postoperatively (change, 24.0 ± 8.0 points; P = .001), and the Hip Outcome Score-Sports Specific Subscale improved from 36.8 ± 19.2 to 82.8 ± 3.8 postoperatively (change, 46.0 ± 18.2 points; P = .002). The pooled risk of postoperative complications was 1.1% (95% CI, 0.1%-2.1%), and the pooled risk of needing revision surgery was 1.0% (95% CI, 0.1%-2.0%). No complication was directly attributed to the AIIS decompression portion of the procedure.

CONCLUSION

PROs improved significantly after hip arthroscopy with AIIS decompression, with a low risk of postoperative complications and subsequent revision surgeries. Failure to identify extra-articular sources of hip pain in outcomes of femoroacetabular impingement syndrome, including from the AIIS, could lead to poorer outcomes and future revision surgery.

Subspine femoroacetabular impingement: retrospective study of a series of patients treated by hip arthroscopic resection

BACKGROUND

Femoroacetabular impingement syndrome (FAIS) is a common hip pathology that causes pain and functional limitation in young patients. subspine femoroacetabular impingement (SFAI) is an increasingly diagnosed extra-articular subtype that occurs from mechanical conflict of the anteroinferior iliac spine (AIIS) with the cervico-diaphyseal junction during hip flexion, which is poorly described in the literature.

QUESTIONS/PURPOSES

We aimed to describe the clinical, functional, and radiological results of the arthroscopic treatment of a group of patients with SFAI treated in our Hip Unit.

STUDY DESIGN

Case series.

METHODS

We present a retrospective study of ten patients with SFAI treated between 2013 and 2020 with arthroscopic resection. Clinical results were assessed with scales such as visual analog scale (VAS); modified Harris Hip Score (mHHS), and Hip disability and Osteoarthritis Outcome Score (HOOS). Radiological results were assessed with radiological measurements, magnetic resonance imaging (MRI), and computed tomography (CT) reconstructions.

RESULTS

Six patients had a Type III AIIS and four of them had Type II. Two patients had previously been surgically treated for FAIS. The range of motion improved in flexion from 107 ± 11 degrees before surgery to 127.5 ± 6 degrees (p = 0.005). MHHS improved from 48.1 (38-75.3) before surgery to 83.1 (57-91) (p = 0.007) and HOOS improved from 65.2 (58-75) to 89 (68.1-100) (p = 0.007). VAS improved from 7.3 (5-9) pre-surgical to 2.5 (0-8) post-surgical (p = 0.005). We did not have significant complications except for an asymptomatic case of heterotopic ossification (Brooker I).

CONCLUSION

Arthroscopic decompression of AIIS in SFAI patients is a safe procedure that provides satisfactory short-term functional results, improving clinical symptoms, function, sports performance, and range of motion in our study.

Isolated, Full-Thickness Proximal Rectus Femoris Injury in Competitive Athletes: A Systematic Review of Injury Characteristics and Return to Play

Background

Characteristics regarding mechanism of injury, management, and return-to-play (RTP) rate and timing are important when treating and counseling athletes with rectus femoris tears.

Purpose

To systematically review the literature to better understand the prevalence, sporting activity, injury mechanisms, and treatment of patients with rectus femoris injury and to provide prognostic information regarding the rate and timing of RTP.

Study Design

Systematic review; Level of evidence, 4.

Methods

Following the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we queried PubMed/MEDLINE, Cochrane, OVID, EMBASE, and Google Scholar in March 2022 for studies reporting on athletes sustaining isolated, full-thickness tearing, or bony avulsion injuries to the proximal rectus femoris during sporting activity. Excluded were studies without evidence of full-thickness tearing or avulsion, with athletes sustaining concomitant injuries, or with injuries occurring from nonsporting activities. The percentage of athletes sustaining injuries was calculated based on sport, injury mechanism, and management (nonoperative versus operative).

Results

Of 132 studies initially identified, 18 were included, comprising 132 athletes (mean age, 24.0 ± 5.4 years; range, 12-43 years). The most common sporting activities were soccer (70.5%) and rugby (15.2%). The most reported mechanisms of injury were kicking (47.6%) and excessive knee flexion/forced hip extension (42.9%). Avulsion injuries were reported in 86% (n = 114) of athletes. Nonoperative management was reported in 19.7% of athletes, with operative management performed in 80.3%. The mean follow-up time was 21.4 ± 11.4 months (range, 1.5-48 months). The RTP rate was 93.3% (n = 14) in nonoperatively treated and 100% (n = 106) in operatively treated athletes, and the mean RTP time was 11.7 weeks (range, 5.5-15.2 weeks) in nonoperatively treated and 22.1 weeks (range, 14.0-37.6 weeks) in operatively treated athletes. Complications were reported in 7.7% (2/26) of nonoperatively treated and 18% (n = 19/106) of operatively treated athletes.

Conclusion

Full-thickness proximal rectus femoris injuries occurred most frequently in athletes participating in soccer and rugby secondary to explosive, eccentric contractions involved in kicking and sprinting. Operative management was performed in the majority of cases. Athletes who underwent operative repair had a 100% RTP rate versus 93.3% in athletes treated nonoperatively.

The management of proximal rectus femoris avulsion injuries

Injuries to the quadriceps muscle group are commonly seen in sporting activities that involve repetitive kicking and high-speed sprinting, including football (soccer), rugby and athletics.

The proximal rectus femoris is prone to avulsion injuries as rapid eccentric muscle contraction leads to asynchronous muscle activation and different force vectors through the straight and reflected heads.

Risk factors for injury include previous rectus femoris muscle or hamstring injury, reduced flexibility of the quadriceps complex, injury to the dominant leg, and dry field playing conditions.

Magnetic resonance imaging (MRI) is the preferred imaging modality as it enables the site of injury to be accurately located, concurrent injuries to be identified, preoperative grading of the injury, and aids surgical planning.

Non-operative management is associated with highly variable periods of convalescence, poor return to preinjury level of function and high risk of injury recurrence.

Operative treatment of proximal rectus femoris avulsion injuries with surgical repair or surgical tenodesis enables return to preinjury level of sporting activity and high functional outcomes.

Surgical tenodesis of proximal rectus femoris avulsion injuries may offer an avenue for further reducing recurrence rates compared to direct suture anchor repair of these injuries.

Cite this article: EFORT Open Rev 2020;5:828-834. DOI: 10.1302/2058-5241.5.200055

Anterior inferior iliac spine avulsion fracture post hip arthroscopy for Femoroacetabular impingement

FAI (Femoroacetabular Impingement) is an uncommon yet reported pathology of the hip joint, especially in the young athletic population. If left untreated, it predisposes for premature osteoarthritis of the hip. FAI treatment modalities consists of either open or arthroscopic surgery, the latter becoming the most adapted modality. We present a case of a young male athlete found to have FAI, treated arthroscopically. His post operative follow up was complicated by anterior inferior iliac spine avulsion fracture due to post op protocol non compliance which was treated with ORIF, with satisfactory non symptomatic outcome.

Femoroacetabular Impingement Patients With Decreased Femoral Version Have Different Impingement Locations and Intra- and Extraarticular Anterior Subspine FAI on 3D-CT-Based Impingement Simulation: Implications for Hip Arthroscopy

BACKGROUND

It remains unclear whether decreased femoral version (FV) causes anterior intra- or extra-articular femoroacetabular impingement (FAI). Therefore, we evaluated symptomatic hips with decreased FV, with and without cam and pincer FAI, by using computed tomography (CT)-based virtual 3-dimensional (3D) impingement simulation and compared this group with patients with normal FV and with asymptomatic hips.

PURPOSE

To investigate (1) the osseous range of motion, (2) the osseous femoral and acetabular impingement zones, and (3) whether hip impingement is extra- or intra-articular in symptomatic hips with FAI.

STUDY DESIGN

Cross-sectional study; Level of evidence, 3.

METHODS

An institutional review board-approved, retrospective comparative analysis was performed on a total of 84 hips in 68 participants. Of these, 37 hips in 24 symptomatic patients with FAI had decreased FV. These hips were compared with 21 hips of 18 symptomatic patients with anterior FAI with normal FV (10°-25°) and 26 asymptomatic hips with no FAI and normal FV. All patients with FAI were symptomatic and had anterior hip pain and a positive anterior impingement test. They underwent pelvic CT scans to measure FV. Decreased FV was defined as FV less than 5°. The 37 hips with decreased FV presented both with and without cam and pincer FAI. All 84 hips were evaluated by use of CT-based 3D models and a validated 3D range of motion and impingement simulation. Asymptomatic hips were contralateral normal hips imaged in patients undergoing total hip arthroplasty.

RESULTS

Hips with FAI combined with decreased FV had a significantly (P < .001) lower mean flexion (114°± 8° vs 125°± 13°) and internal rotation (IR) at 90° of flexion (18°± 6° vs 32°± 9°, P < .001) compared with the asymptomatic control group. Symptomatic patients with FAI and normal FV had flexion of 120°± 16° and IR at 90° of flexion of 23°± 15°. In a subgroup analysis, we found a significantly (P < .001) lower IR in 90° of flexion in hips with FV less than 5° combined with mixed-type FAI compared with hips with FV less than 5° without a cam- or pincer-type deformity. The maximal acetabular impingement zone for hips with decreased FV was located at the 2-o'clock position and ranged from 1 to 3 o'clock. In hips with decreased FV, most of the impingement locations were intra-articular but 32% of hips had combined intra- and extra-articular FAI in internal rotation in 90° of flexion. During the flexion-adduction-IR test performed in 10° and 20° of adduction, extra-articular subspine FAI had significantly (P < .001) higher prevalence (68% and 84%) in hips with decreased FV compared with normal hips.

CONCLUSION

Hips with FAI and decreased FV had less flexion and internal rotation in 90° of flexion compared with the asymptomatic control group. The majority of hip impingement due to low FV was intra-articular, but one-third of samples had combined intra- and extra-articular subspine FAI. Anterior extra- and intra-articular hip impingement can be present in patients who have FAI with decreased FV. This could be important for patients undergoing hip arthroscopy.

Arthroscopic excision of heterotopic ossification in the rectus femoris muscle causing extra-articular anterior hip impingement

Subspine impingement is an extra-articular hip impingement syndrome that usually occurs when there is abnormal contact between an enlarged or malorientated anterior inferior iliac spine (AIIS) and the distal anterior femoral neck in straight flexion of the hip. We present the case of a 13-year-old boy with a history of left groin pain and loss of range of movement of the hip for over six months following an avulsion fracture of the AIIS during a game of rugby. He was diagnosed with subspine impingement secondary to a large lesion of heterotopic ossification in the rectus femoris; this was dissected and extracted from the muscle in toto arthroscopically. This case highlights the importance of heterotopic ossification after injury as an important cause for subspine impingement in the young adult hip. This is the first report and describes subspine impingement secondary to a large lesion of heterotopic ossification.

[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.

Operative Fixation of an Anterior Inferior Iliac Spine Apophyseal Avulsion Fracture Nonunion in an Adolescent Soccer Player: A Case Report

CASE

A 14-year-old male competitive soccer player presented with a history of recurrent right hip pain for 18 months. He was diagnosed with an anterior inferior iliac spine (AIIS) apophyseal avulsion fracture nonunion with subspinal impingement, which was confirmed by radiographs, computed tomography, and magnetic resonance imaging. The patient underwent surgical fixation and subspinal decompression. He returned to competitive soccer 5 months postoperatively.

CONCLUSION

AIIS apophyseal avulsion fractures occur in adolescent athletes and generally respond to nonoperative treatment. When such management is unsuccessful, surgical fixation can lead to resolution of pain with return of full function.

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.

Arthroscopic Decompression of a Type III Subspine Impingement

Extra-articular hip impingement refers to a variety of hip disorders causing pain and limited function in young, non-arthritic patients. Recently, there has been an increased focus on analyzing the degree of anterior inferior iliac spine (AIIS) dysmorphism and its correlation with subspine impingement (SSI), defined as abutment between a prominent distal aspect of the AIIS and the anterior aspect of the femoral head-neck junction. Arthroscopic decompression of the AIIS is recognized as an effective treatment for SSI. However, there may be some inherent risks of performing this procedure arthroscopically that require further investigation.