Anatomic Footprint of the Direct Head of the Rectus Femoris Origin: Cadaveric Study and Clinical Series of Hips After Arthroscopic Anterior Inferior Iliac Spine/Subspine Decompression

Department of Orthopedic Surgery, Dokuz Eylul University, Izmir, Turkey.
Arthroscopy The Journal of Arthroscopic and Related Surgery (Impact Factor: 3.21). 10/2013; 29(12). DOI: 10.1016/j.arthro.2013.08.023
Source: PubMed


The purposes of this study were to define the anatomy of the anterior inferior iliac spine (AIIS) and its relation to the footprint of the rectus femoris tendon and to evaluate on the clinical outcomes after AIIS/subspine decompression.
The rectus origin was dissected and detached in 11 male cadaveric hips with a mean age of 54.3 ± 14.3 years (range, 33 to 74 years). The proximal-distal and medial-lateral extent of the footprint and its relation to the AIIS and acetabular rim were evaluated, with the 12-o'clock position defined as directly lateral at the insertion of the indirect head of the rectus tendon and the 1- to 6-o'clock positions defined as anterior acetabular positions. To assess the safety and efficacy of subspine decompression for AIIS deformity, clinical correlation of a series of 163 AIIS decompressions (mean age, 27.8 years; age range, 14 to 52 years) performed from January 2011 to January 2012 was completed, and outcome scores, strength deficits, and ruptures were assessed by manual muscle testing and postoperative radiographs. All patients presented with symptomatic FAI with proximal femoral and/or acetabular deformity and type 2 (131 hips) or type 3 (32 hips) AIIS morphology as defined by Hetsroni et al.
The mean proximal-distal and medial-lateral distances for the rectus origin footprint were 2.2 ± 0.1 cm (range, 2.1 to 2.4 cm) and 1.6 ± 0.3 cm (range, 1.2 to 2.3 cm), respectively. There was a characteristic bare area at the anteromedial AIIS. On the clock face, the lateral margin (1-o'clock to 1:30 position) and medial margin (2-o'clock to 2:30 position) of the AIIS and the indirect head of the rectus (12 o'clock) were consistent for all specimens. In the clinical series, 163 AIIS decompressions were performed for symptomatic subspine impingement. The mean modified Harris Hip Score was 63.1 points (range, 21 to 90 points) preoperatively compared with 85.3 points (range, 37 to 100 points) at a mean follow-up of 11.1 ± 4.1 months (range, 6 to 24 months) (P < .01). Short Form 12 scores improved significantly from a mean of 70.4 (range, 34 to 93) preoperatively to a mean of 81.3 (range, 31 to 99) postoperatively (P < .01). The mean pain score on a visual analog scale also improved significantly from a mean of 4.9 (range, 0.1 to 8.6) preoperatively to a mean of 1.9 (range, 0 to 7.8) postoperatively (P < .01). The mean alpha angle improved from 61.5° (range, 35° to 90°) preoperatively to 49° (range, 35° to 63°) postoperatively on anteroposterior radiographs and from 71° (range, 45° to 90°) preoperatively to 44.3° (range, 37° to 60°) postoperatively on lateral radiographs. No short- or long-term hip flexion deficits or rectus femoris avulsions were noted with up to 2 years' follow-up.
The origin of the rectus femoris tendon is broad on the AIIS and protective against direct head detachment with subspine decompression. This broad origin and consistent bare area anteromedially on the AIIS can be readily used by surgeons to perform a safe AIIS resection in cases of symptomatic impingement. Arthroscopic subspine decompression in addition to osteoplasty for symptomatic cam- and/or pincer-type FAI deformities can reliably improve outcome scores without significant hip flexion deficits or AIIS/rectus femoris avulsions.
The direct head of the rectus tendon has a broad insertion on the AIIS, and an area devoid of tendon provides a "safe zone" for subspine decompression in cases of symptomatic AIIS impingement.

Download full-text


Available from: Mustafa Güvençer, Jun 16, 2015
  • Source
    • "Currently of interest are extra-articular sources of FAI, which may cause a small proportion of FAI cases and are exemplified by trochanteric-pelvic, ischiofemoral and subspine impingement (Pan et al., 2011; Hapa et al., 2013; de Sa et al., 2014). "
    [Show abstract] [Hide abstract]
    ABSTRACT: Femoroacetabular impingement syndrome (FAI) is a clinical entity that has been recognized in recent years as a frequent cause of pain and the early development of hip arthrosis. Subspine hip impingement is characterized by the prominent or abnormal morphology of the anteroinferior iliac spine (AIIS), which contributes to the development of a clinical picture that is similar to FAI. The aims of this study were to propose a new morphological classification of the AIIS, to determine the prevalence of the different AIIS morphologies based on this classification and to correlate the presence of said morphologies with different gender and age groups. The sample consisted of 458 hemipelvises from individuals of known age and sex (264 men and 194 women). Each specimen was analyzed to determine the prevalence of each of the different morphologies of the AIIS based on the classification proposed as Type 1: the presence of a concave surface between the AIIS and the acetabular rim; Type 2A: the presence of a flat surface between the AIIS and the acetabular rim; Type 2B the presence of a convex surface between the AIIS and the acetabular rim; and Type 3: the AIIS protrudes inferiorly toward the anterior acetabulum. A prevalence of 69.87% was determined for Type 1 AIIS (320/458). In regard to abnormal morphology, prevalences of 17.90% (82/458), 3.71% (17/458) and 8.52% (39/458) were determined for type 2A, Type 2B and Type 3, respectively. The prevalence of abnormal AIIS morphology was 30.30% (80/264) in male specimens and 29.90% (58/194) in female specimens. This study demonstrates the prevalence of the different morphologies of the AIIS, providing information that will be useful in determining the role of the AIIS in the emergence of subspine hip impingement.
    Full-text · Article · Jun 2015 · International Journal of Morphology
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Extra-articular hip impingement can be the result of psoas impingement (PI), subspine impingement (SSI), ischiofemoral impingement (IFI), and greater trochanteric/pelvic impingement (GTPI). Symptoms may be due to bony abutment or soft-tissue irritation, and often, it is a challenge to differentiate among symptoms preoperatively. Currently, the clinical picture and diagnostic criteria are still being refined for these conditions. This systematic review was conducted to examine each condition and elucidate the indications for, treatment options for, and clinical outcomes of surgical management. We searched online databases (Medline, Embase, and PubMed) for English-language clinical studies published from database inception through December 31, 2013, addressing the surgical treatment of PI, SSI, IFI, and GTPI. For each condition, 2 independent assessors reviewed eligible studies. Descriptive statistics are presented. Overall, 9,521 studies were initially retrieved; ultimately, 14 studies were included examining 333 hips. For PI, arthroscopic surgery resulted in 88% of patients achieving good to excellent results, as well as significant improvements in the Harris Hip Score (P = .008), Hip Outcome Score-Activities of Daily Living (P = .02), and Hip Outcome Score-Sport (P = .04). For SSI, arthroscopic decompression, with no major complications, resulted in a mean 18.5° improvement in flexion range of motion, as well as improvements in pain (mean visual analog scale score of 5.9 points preoperatively and 1.2 points postoperatively) and the modified Harris Hip Score (mean of 64.97 points preoperatively and 91.3 points postoperatively). For both IFI and GTPI, open procedures anecdotally improved patient symptoms, with no formal objective outcomes data reported. This review suggests that there is some evidence to support that surgical treatment, by arthroscopy for PI and SSI and by open surgery for IFI and GTPI, results in improved patient outcomes. Systematic review of Level IV and V (case report) studies.
    Full-text · Article · May 2014 · Arthroscopy The Journal of Arthroscopic and Related Surgery
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: This study aimed to define the footprint of the direct and reflected heads of the rectus femoris and the relation of the anterior inferior iliac spine (AIIS) to adjacent neurovascular (lateral circumflex femoral artery and femoral nerve), bony (anterior superior iliac spine [ASIS]), and tendinous structures (iliopsoas). Twelve fresh-frozen cadaveric hip joints from 6 cadavers, average age of 44.5 (±9.9) years, were carefully dissected of skin and fascia to expose the muscular, capsular, and bony structures of the anterior hip and pelvis. Using digital calipers, measurements were taken of the footprint of the rectus femoris on the AIIS, superior-lateral acetabulum and hip capsule, and adjacent anatomic structures. The average dimensions of the footprint of the direct head of the rectus femoris were 13.4 mm (±1.7) × 26.0 mm (±4.1), whereas the dimensions of the reflected head footprint were 47.7 mm (±4.4) × 16.8 mm (±2.2). Important anatomic structures, including the femoral nerve, psoas tendon, and lateral circumflex femoral artery, were noted in proximity to the AIIS. The neurovascular structure closest to the AIIS was the femoral nerve (20.8 ± 3.4 mm). The rectus femoris direct and reflected heads originate over a broad area of the anterolateral pelvis and are in close proximity to critical neurovascular structures, and care must be taken to avoid them during hip arthroscopy. A thorough knowledge of the anatomy of the proximal rectus femoris is valuable for any surgical exposure of the anterior hip joint, particularly arthroscopic subspine decompression and open femoroacetabular impingement (FAI) surgery.
    Full-text · Article · May 2014 · Arthroscopy The Journal of Arthroscopic and Related Surgery
Show more