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

Abstract

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.

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

“…They usually are a result of forceful kicking with abrupt arrest, causing avulsion of the rectus femoris at the anterior infericor iliac spine. Other described mechanisms consist of sudden deceleration in running sports and hip hyperextension with a flexed knee [ 7 ]. It has been postulated that patients who underwent hip arthroscopy for FAI are prone to these injuries more than individuals with no previous surgery, lowering the threshold for injury [ 7 ].…”

“…This report discusses the case of a 21-year-old male patient who was found to have an anterior inferior iliac spine avulsion fracture 11 months post hip arthroscopy for femoroacetabular impingement. According to a review of literature on hip arthroscopy complications, few similar cases were reported [ 7 ].…”

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

“…In this case, the heterotopic ossification lesion was large in size, and pathomorphology and treatment were in accordance with those in Type III. Arthroscopic resection of the AIIS for subspine impingement is thought of as a relatively safe procedure, although a case of avulsion of the rectus femoris direct head following revision hip arthroscopy for the treatment of subspine impingement in a 23-year-old professional footballer was reported recently [ 17 ].…”

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

“… 18 During the focal subspinal decompression, however, over-resection of the subspinal area should be avoided, because the rectus femoris could be detached from its origin, leading to a potential hip flexion deficit. 19 To minimize this risk, we carefully conduct a dynamic impingement test during hip arthroscopy.…”