Post-traumatic ossifications of the rectus femoris: Arthroscopic treatment and clinical outcome after 2 years

Post-traumatic

ossi

fications

of

the

rectum

femoris:

Arthroscopic

treatment

and

clinical

outcome

after

2

years

Raul

Zini

,

Manlio

Panascì

*

a

MariaCeciliaHospital,GVMCareandResearch,Ravenna,Italy

b

SanCarlodiNancyHospital,GVMCareandResearch,Rome,Italy

ARTICLE INFO Articlehistory: Received24June2018

Receivedinrevisedform29September2018 Accepted30September2018 Keywords: hip rectusfemoris groinpain arthroscopy sport-injury ABSTRACT

Injuriesoftherectusfemoristendonorigincouldresultinachronictendinopathy,leadingtogroinpain andlossoffunction.

Conservativetreatmentwithanalgesicsandphysicaltherapyisthegoldstandard,butinsomecases excessiveboneformationafteravulsioninjuries,canleadtoapost-traumaticheterotopicossification (PHO)andmaybenefitfromsurgicalremoval.

Methods:Outcomewasevaluatedin16topsoccerplayers(age24-43years)affectedbycalcificationofthe proximalrectuswhounderwentarthroscopicexcision(6-12and24months).X-rayand3DCTwas collectedforallpatients.HipdisabilityandOsteoarthritisOutcomeScore,OxfordHipScore,Modified HarrisHipScore,togetherwithvisualanalogscales(VAS)forpain,sportactivitylevel(SAL),andactivities ofdailyliving(ADL)wereusedtoevaluateclinicaloutcome.

Technicalprocedure:aftercentralcompartmentexaminationandtreatmentwasaccomplished,attention was focusedto theossificationoftherectusfemoris.Acomplete exposureoftheossificationwas achieved;whenpossibleattentionwastakenindetachingtheminimumamountoffibersofthedirect headoftherectusfemorisfromitsinsertionsite.Duringtheentireprocedure,bothdynamicdirect visualizationandfluoroscopicevaluationoftheamountofresectionwereperformed.

Results:Clinicaloutcomewasexcellent;thepercentageofreturntopre-injurylevelsportwas68.75%(11 athletes),withsignificantstatisticalimprovementofMHHS,OHSandall3VASsubscalesinallpatientsat 2yearsfollow-up.

Conclusion:Arthroscopicremovalusingconventionalhiparthroscopicportalsrepresentbotheffective andsafeproceduretoadequatelytreatpost-traumaticossificationoftherectusfemoris.

©2018ElsevierLtd.Allrightsreserved.

Introduction

Post-traumatic heterotopic ossi_fication (PHO) of the rectus femoris can be very disabling in athletes, with most injuries occurringatthemyotendinousjunction.Mostoftheseinjuriescan be successfully managed with conservative treatment. Hip arthroscopicsurgicaltechniquesaroundthehipjointhavebecome verycommon,addressingperitrochantericdisorders,deepgluteal syndrome,andhamstringtendontear.[1,7,11,23,29].Thefocusof this retrospective case-series study is to evaluate longer-term resultsfromourpreviousstudyonthearthroscopicapproachto treatPHOoftherectusfemoris[31].

MaterialsandMethods

SixteenconsecutivemalepatientspresentedtoOurinstitution betweenSeptember2009andJuly2015forchronic(>6months) pain and impaired function of the hip, unresponsive to non-steroidalanti-inflammatorydrugs(NSAIDs)andphysicaltherapy. Allpatientsweresoccerplayers.Nonehadahistoryofpreviouship issuesor

other significantrecorded trauma.Patientscomplainedof painattheanterioraspectofthehip,limitedhipextension.A standardradiographshowedaPHOclosetothesuperioraspect ofthe acetabulum. (Figs.1 and 2 )A computedtomography scan was performed in all patients, which con_firmed the presence of a calcification of the direct head of the rectus femoris. Patients were therefore indicated for arthroscopic excisionofthe PTO.

*Correspondingauthor.

E-mailaddress:studiopanasci@gmail.com(M.Panascì).

https://doi.org/10.1016/j.injury.2018.09.062

0020-1383/©2018ElsevierLtd.Allrightsreserved.

ContentslistsavailableatScienceDirect

Injury

StatisticalAnalysis

Preoperative and postoperative values were expressed as median and 95% CI, and were compared using the Wilcoxon pairedsamplestest.Thelevelofstatisticalsignificancewassetat p_<0.050. Data analyses were performed using STATA v.11 (StataCorp,CollegeStation,TX).

OutcomeEvaluation

Toevaluatetheoutcome,pre-andpostoperative(6,12and24 months) standardized hip rating scores were used: the Hip disabilityand OsteoarthritisOutcomeScore(HOOS)[25]Oxford Hip Score (OHS) [9], and modified Harris Hip Score (mHHS)[]. Moreover,visualanalogscales(VASs)wereusedforpain, sport activitylevel(SAL),andactivitiesofdailyliving(ADL),expressedas asubjectivevaluebetween0and100(100=pre-injurysportlevel, 0=inabilitytoplaysport)(Table1).

SurgicalTechnique

Astandardfracturetablewasusedwiththepatientinasupine position[4].Theoperativelimbwasplacedwiththehipinslight abduction and internal rotation. The contralateral limb was positionedin extensionand neutralrotation,withthefootina support applying a counterbalancing traction. Countertraction, lateralizedtowardtheoperativehip,was placedintheperineal region.Twostandardportalswereused.Usingthe70_arthroscope,

theanterolateralportal(ALP)wasperformed.TheALPprovidesa completeviewofthecentralcompartment forthetreatment of possibleassociatedintra-articularpathologies.Onceinsidethehip jointwiththecamerathroughtheALP,themid-anteriorportalwas created via direct visualization. Anarthroscopicknife (Samurai blade; Stryker) was introduced to perform an interportal capsulotomy parallel to the labrum. Coagulation of bleeding vessels was achieved with a radiofrequency device (Smith & Nephew). The central compartment was addressed first.

Fig.1and2.Imageshowingossificationoftherectusfemoris.Post-opx-rayshowingcompleteexcisionofthePHO.

Table1

Pre-andPostoperativePainandFunctionScoresa

Measure Preoperative(MeanSD) Postoperative PValue

6Months(MeanSD) 12Months(MeanSD) 24MonthsMenaSD) Preoperativevs24Months HOOS 44.424.0 77.77.2 91.18.0 90.18.0 <.05 mHHS 70.86.0 86.99.3 96.94.4 97.94.4 <.05 OHS 37.55.0 40.22.1 46.50.8 47.50.8 <.05 VAS Pain 4.31.1 2.31.1 0.20.4 <0.20.4 <.05 ADL 71.614.6 80 98.33.7 98.43.5 <.05 SAL 18.326.0 71.66 91.68.9 90.48.4 <.05 a

ADL,activitiesofdailyliving;HOOS,HipdisabilityandOsteoarthritisOutcomeScore;mHHS,modifiedHarrisHipScore;NS,notsignificant;OHS,OxfordHipScore;SAL, sportactivitylevel;VAS,visualanalogscale.

Concomitantlesions(labral tear,chondrallesion,impingement) wereevaluatedandeventuallytreated.Aftercentralcompartment examination and treatment was completed, the traction was removedand attention was focused tothe calcification of the rectusfemoris.Ashaverwasusedtoclearallsofttissuefromthe overhangingacetabulumandtobetterdelimittheplanebetween theacetabularrimandthecalcification.Usinganextra-long, 5.5-mm full-radius shaver and a radiofrequency device, complete exposureofthecalcificationwasachieved(Fig.3).Whenpossible, carewastakenindetachingtheminimumamountoffibersofthe directheadoftherectusfemorisfromitsinsertionsite.Usingthe imageintensi_fierasaguide,thecalci_ficationwasremovedusinga 5.5-mmbur(Figs.4–6).Duringtheentireprocedure,bothdynamic directvisualizationandfluoroscopicevaluationoftheamountof resectionwereperformed.Patientsweredischargedthedayafter theprocedure.Weight-bearingwaspermittedastolerated,butthe extensionofthehipwasforbiddenfor3weekstoavoidexcessive elongationof therectusfemoristendon. To avoidrecurrence,a courseofcelecoxibwasprescribed(200mg/dfor4weeks). Results

Theaverageageofthepatientswas26,6years(range,24-43 years).Themeantimefromsymptomstosurgerywas10.2months. Aftersurgery,allpatientsreportedsatisfactoryoutcomes,with11 of18patientsratingtheirreturntosportlevelashighaspre-injury (P<.05),andtheremaining6returnedatapercentageabove80% accordingtotheSALscoreatameanof8weeks(range,4-9weeks) fromsurgery.Seventeenof18patientsrankedtheirabilitytocarry on daily activities as 100%. The minimum follow–up was 24 months.Themean time tosportactivity returnwas 42.8days. Comparingpre-withpostoperativevaluesat2yearfromsurgery, thestatisticalanalysisshowedsignificantimprovementforHOOS (mean,90.18),OHS(mean,47.50.8),mHHS(mean,97.94.4), andtheVASforpain(mean,0.20.4),ADL(mean,98.43.5),and SAL(mean,90.48.4)frompre-topostoperative(P< .05).

Discussion

APHOoftherectusfemoristendonisararecondition,mostly affectingathletes,thatcancausehippainandimpairment[12]. Other possible causes of hip pain coming from rectus femoris origin include os acetabuli, avulsion fractures, and myositis ossificans[17,29].Generally,acalcificdepositwithinthetendon of the rectus femoris can be visualized on radiograph as a formationusuallyparalleltothelongaxisofthefemur(seeFigure1

Fig.1).Variousetiopathogenetichypotheseshavebeenproposed, suchasconsequenceofapreviousinjury[30].Localstressnecrosis [6] has been suggested as the first step for the deposition of calcium salts, either directly or through fatty acid and soap intermediaries.Amorerecenttheoryproposedtherole oflocal hypoxia as a cause secondary toeither mechanical orvascular

Fig.3.Completeexposureofthepost-traumaticHeterotopicossificationofthe rectusfemoris.

Fig.4.Arthroscopicviewsduringrectusfemorisossificationremoval.

factors [29]. In this series, 2 cases presented the tendon calcificationtogetherwithalabraltear.Arelativelyrecentpaper describedanewpathologicalentity,thehipanterosuperiorlabral tearwithavulsionofrectusfemoris(HALTAR)[19].

Traditionaltreatmentfor calcifictendinitisof rectus femoris includedoralNSAIDs[18,27],andpreviously,radiotherapy[21].All the treatment options give the possibility of recovery from symptoms.In refractorycases or when a largebone formation occurs(ie,traumaticinjuries),asurgicalexcisionofthecalci fica-tionmaybenecessary,traditionallyperformedthroughananterior approach[3].Hiparthroscopyhasgiventheopportunitytoreduce tissuedamage andhavea fasterrecovery.In addition,it allows concomitantintra-andextra-articulardisorderssuchusa femoro-acetabularimpingementtobeaddressed.

Thisistoourknowledgethelargestpublishedseriesofrectus femoris tendon calcification in top amateur athletes (soccer players) to date with a follow up of at least 24months. El-Husseinyetal.[12]reported1caseofarthroscopicexcisionof heterotopicossificationinachronicrectusfemorisorigininjury. Thepatient was pain-free and able to return tofull training within 8 weeks. Peng et al. [26] reported on 3 patients (age range,38-55years)affectedbyacalcifictendinitisoftherectus femoris tendon addressed using arthroscopic excision. At 9-month follow-up, all 3 patients were pain-free and had recoveredfullfunction.A recentstudyshowedagoodclinical outcome using the endoscopic approach to remove the ossification.We think this is a validsurgical option incases where a central compartment evaluation is not necessary, althoughnodataareevaluabletocompareitwithatraditional trans-capsular approachin terms of time recovery, complica-tionsorrecurrencerate[7].

Limitationsofthestudyincludethesmallnumberofpatients andthefactthatitwasaretrospectivestudy.Nocomplications werereported during thefollow-up period, patients needed a shorthospitalization(1night)andimmediatelystarted rehabili-tation.Asaminimallyinvasivesurgery,themain advantagesof hip arthroscopy are minimal damage to the soft tissues surrounding the hiparea andrapid recovery [13]. In addition, itprovidestheopportunitytoaddressconcomitantlesions,such as labral tear, femoro-acetabular impingement, and cartilage lesions[2,13].

Conclusion

Post-traumaticossificationoftherectusfemorisisassociatedwith sportsinvolvingpowerfulandrepetitivehipmovementthroughfull therangeofmotion.Thearthroscopicapproachcanbeconsidereda feasibleandeffectiveoption,withfewrisksforthepatients,rapid recovery,andimprovedresultsatlong-termfollow-up.

Conflictofinterest

Theauthorswhosenamesarelistedimmediatelybelowcertifythat theyhaveNOaf_filiationswithorinvolvementinanyorganizationor entity with anyfinancialinterest(suchashonoraria;educationalgrants; participationinspeakers’bureaus;membership,employment, consul-tancies,stockownership,orotherequityinterest;andexperttestimony orpatent-licensingarrangements),ornon-financialinterest(suchas personal or professional relationships, affiliations,knowledgeorbeliefs) inthesubjectmatterormaterialsdiscussedinthismanuscript. References

[1]BenantiJ.C., GramlingP, BulatPI,ChenP, LundstromG.Retropharyngeal calcifictendinitis:reportoffivecasesandreviewoftheliterature.JEmerg Med.1986;4:15–24.

[2]BozicKJ,ChanV,ValoneFH.3rd,FeeleyBT,VailTP.Trendsinhiparthroscopy utilizationintheUnitedStates.JArthroplasty.2013;28(8suppl):140–3. [3]Braun-MoscoviciY,SchapiraD,NahirAM.Calcifictendinitisoftherectus

femoris.JClinRheumatol.2006;12:298–300.

[4]Byrd JW. Hip arthroscopy utilizing the supine position. Arthroscopy. 1994;10:275–80.

[6]CarrollRE,SeitzJrWH,PutnamMD.Acutecalciumdepositinthehandofan 11-year-oldgirl.JPediatrOrthop.1985;5:468–70.

[7]CombaF,PiuzziNS.EndoscopicExtraarticularSurgicalRemovalofHeterotopic OssificationoftheRectusFemorisTendoninaSeriesofAthletes.OrthopJ SportsMed.2016;4(September(9)).

[9]DawsonJ,FitzpatrickR,CarrA,MurrayD.Questionnaireontheperceptionsof patientsabouttotalhipreplacement.JBoneJointSurgBr.1996;78:185–90. [11]DombBG,NasserRM,BotserIB.Partial-thicknesstearsofthegluteusmedius:

Rationaleandtechniquefortrans-tendinousendoscopicrepair.Arthroscopy. 2010;26:1697–705[PubMed].

[12]El-HusseinyM,SukeikM,HaddadFS.Arthroscopicexcisionofheterotopic calcificationinachronicrectusfemorisorigininjury:acasereport.AnnRColl SurgEngl.2012;94(3):e129–131.

[13]EnsekiKR,MartinRL,DraovitchP,KellyBT,PhilipponMJ,SchenkerML.Thehip joint:arthroscopicproceduresandpostoperativerehabilitation.JOrthop SportsPhysTher.2006;36:516–25.

[17]HodgeJC,Schneider R,FreibergerRH,MagidSK.Calcifictendinitisinthe proximalthigh.ArthritisRheum.1993;36:1476–82.

[18]HoltPD,KeatsTE. Calcifictendinitis:areviewoftheusualandunusual. SkeletalRadiol.1993;22:1–9.

[19]HosalkarHS,PennockAT,ZapsD,SchmitzMR,BomarJD,BittersohlB.Thehip antero-superiorlabraltearwithavulsionofrectusfemoris(HALTAR)lesion: doestheSLAPequivalentinthehipexist?HipInt.2012;22:391–6. [21]KingJW,VanderpoolDW.Calcifictendonitisoftherectusfemoris.AmJOrthop.

1967;9:110–1.

[23]MartinHD,ShearsSA,JohnsonJC,SmathersAM,PalmerIJ.Theendoscopic treatmentofsciaticnerveentrapment/deepglutealsyndrome.Arthroscopy. 2011;27:172–81.

[25]OuelletteH,ThomasBJ,NelsonE,TorrianiM.MRimagingofrectusfemoris origininjuries.SkeletalRadiol.2006;35:665–72.

[26]PengX,FengY,ChenG,YangL.Arthroscopictreatmentofchronicallypainful calcifictendinitisoftherectusfemoris.EurJMedRes.2013;18:49. [27]PopeJrTL,KeatsTE.Casereport733.Calcifictendinitisoftheoriginofthe

medialandlateralheadsoftherectusfemorismuscleandtheanterioriliac spine(AIIS).SkeletalRadiol.1992;21:271–2.

[29]SarkarJS,HaddadFS,CreanSV,BrooksP.Acutecalcifictendinitisoftherectus femoris.JBoneJointSurgBr.1996;78:814–6.

[30]UhthoffHK,SarkarK,MaynardJA.Calcifyingtendinitis:anewconceptofits pathogenesis.ClinOrthopRelatRes.1976;(118):164–8.

[31]ZiniR,PanascìM,PapaliaR,FranceschiF,VastaS,DenaroV.Rectusfemoris tendoncalcification:arthroscopicexcisionin6topamateurathletes.OrthopJ SportsMed.2014;2(12).

Furtherreadings

[5]ByrdJW,JonesKS.Prospectiveanalysisofhiparthroscopywith2-year follow-up.Arthroscopy.2000;16:578–87.

[8]CoxD,PatersonFW.Acutecalcifictendinitisofperoneuslongus.JBoneJoint SurgBr.1991;73:342.

[10]DilleyDF,TonkinMA.Acutecalcifictendinitisinthehandandwrist.JHand SurgBr.1991;16:215–6.

[14]GamradtSC,BrophyRH,BarnesR,WarrenRF,ThomasByrdJW,KellyBT. Nonoperativetreatmentforproximalavulsionoftherectusfemorisin professionalAmericanfootball.AmJSportsMed.2009;37:1370–4. [15]HarrisJD,McCormickFM,AbramsGD,etal.Complicationsandreoperations

duringandafterhiparthroscopy:asystematicreviewof92studiesandmore than6,000patients.Arthroscopy.2013;29:589–95.

[16]HetsroniI,LarsonCM,DelaTorreK,ZbedaRM,MagennisE,KellyBT.Anterior inferioriliacspinedeformityasanextra-articularsourceforhipimpingement: aseriesof10patientstreatedwitharthroscopicdecompression.Arthroscopy. 2012;28:1644–53.

[20]KimYS, Lee HM, KimJP. Acute calcifictendinitis of the rectus femoris associatedwithintraosseousinvolvement:acasereportwithserialCTandMRI findings.EurJOrthopSurgTraumatol.2013;23(suppl2):S233–9.

[22]LarsonCM,KellyBT,StoneRM.Makingacaseforanteriorinferioriliacspine/ subspinehipimpingement:threerepresentativecasereportsandproposed concept.Arthroscopy.2011;27:1732–7.

[24]Nilsdotter AK, Lohmander LS, Klassbo M, Roos EM. Hip disability and osteoarthritisoutcomescore(HOOS)—validityandresponsivenessintotal hipreplacement.BMCMusculoskeletDisord.2003;4:10.

[28]PoleselloGC,QueirozMC,DombBG,OnoNK,HondaEK.Surgicaltechnique: Endoscopicgluteusmaximustendonreleaseforexternalsnappinghip syndrome.ClinOrthopRelatRes.2013;471:2471–6.