Endoscopic Surgical Removal of Calcific Tendinitis of the Rectus Femoris: Surgical Technique

Abstract

Calcific tendinitis of the rectus femoris (CTRF) is an under-recognized condition and, because of its self-limiting nature, is usually managed conservatively. Nevertheless, when nonsurgical therapy fails, further invasive alternatives are required. At this point, arthroscopic resection provides a minimally invasive and interesting alternative to open surgery. The aim of this work is to report the surgical technique of endoscopic surgical removal in patients with CTRF at the periarticular region of the hip joint. Endoscopic surgical removal of CTRF was performed without traction following anatomic landmarks for hip arthroscopy portal placement. We used the anterolateral portal and the proximal accessory portal to obtain access to the lesion. A shaver and radiofrequency device are useful tools to depict the calcific lesion while the whole resection is performed with a 5-mm round burr. Intraoperative fluoroscopy control during the entire procedure is essential. Endoscopic treatment of calcific tendinitis of the hip is a valuable technique in the treatment of patients who do not respond to conservative treatment.

Calcific tendinitis is a common disease and results from calcium hydroxyapatite crystal deposition in muscles, tendons, and periarticular areas.¹ Calcific tendinitis of the rectus femoris (CTRF), first recognized in 1967 by King and Vanderpool,² is a rare disease,³ but a few cases have been reported.4, 5, 6, 7, 8 The etiology is not clear and seems to be multifactorial: Traumatic,¹ genetic,⁹ and local metabolic factors¹⁰ have been postulated as mechanisms of calcific tendinitis.

Because of its self-limiting nature, calcific tendinitis is usually managed conservatively with rest, heat/cold, physical therapy, nonsteroidal anti-inflammatory drugs,¹¹ or extracorporeal shock wave therapy.¹² Further invasive alternatives are used when conservative therapy fails,¹³ with treatment options including local steroid or anesthetic injections,6, 8 open surgical removal,¹¹ or endoscopic removal.7, 14, 15 Arthroscopic resection provides a minimally invasive technique for removal of intractable CTRF and has a rapid recovery. The purpose of this study is to describe our endoscopic surgical removal technique for CTRF at the periarticular region of the hip joint (Fig 1).

Fig 1.

Preoperative (A) anteroposterior and (B) lateral radiographic views of the right hip show calcification near the superior lip of the acetabulum (arrows). Postoperative (C) anteroposterior and (D) lateral views show complete resection of the calcification after endoscopic surgery.

Surgical Technique

The patient is placed in the supine position on a traction table with the limb in 15° of abduction and neutral rotation without traction (Video 1). A C-arm image detector is centered over the operative hip. The relevant landmarks for safe portal placement are the anterior superior iliac spine, greater trochanter, and femoral pulse. We use 2 portals: anterolateral portal (1 cm proximal and 1 cm anterior to the tip of the greater trochanter) and proximal accessory portal (3 to 4 cm proximal to the first portal). The conventional anterolateral portal is established first, and a 15-gauge spinal needle is introduced pointing directly to the calcific lesion under fluoroscopic control. The solid bone corresponding to the lesion serves as a stop as it is touched with the needle (Fig 2). Subsequently, a nitinol wire is inserted through the needle and a cannula trocar is assembled over the needle wire. Through this portal, we prefer to use a 70° arthroscope (Arthrex, Naples, FL) because we routinely perform hip arthroscopies with a 70° arthroscope, although this procedure can also be performed with a 30° arthroscope.

Fig 2.

With the patient placed in the supine position on a traction table with the limb in 15° of abduction and neutral rotation without traction, (A) an anteroposterior fluoroscopic image and (B) clinical photograph show the conventional anterolateral portal being established with introduction of a 15-gauge spinal needle pointing directly to the calcific lesion.

Consequently, a second spinal needle is placed through a proximal accessory hip arthroscopy portal aiming toward the calcific lesion under fluoroscopic control and direct visualization (Fig 3A). The same sequence described before is used to establish the portal (Fig 3 B and C). Operating a 4.5-mm motorized shaver (Arthrex), we proceed to resect the soft-tissue layer that surrounds the lesion, generating a space around it (Fig 4A).

Fig 3.

(A) An anteroposterior fluoroscopic image shows a cannula trocar assembled in the anterolateral portal through a nitinol wire inserted through the previously established spinal needle. Subsequently, a second spinal needle is placed through a proximal accessory hip arthroscopy portal aiming toward the calcific lesion under fluoroscopic control and direct visualization. (B) An anteroposterior fluoroscopic image and (C) clinical photograph show both portals after establishment.

Fig 4.

Extracompartmental arthroscopic views in a right hip (70° arthroscope in anterolateral portal and shaver in proximal accessory portal). (A) The endoscopic view shows resection, with a shaver, of the soft-tissue layer that surrounds the calcific tendinitis lesion (asterisks), generating a space around it. (B) Afterward, radiofrequency ablation is used to perform hemostasis and local bleeding control.

Use of a radiofrequency ablation device (Arthrex) at this point is convenient to perform hemostasis and control local bleeding, serving also to define the lesion limits from proximal to distal and from posterior to anterior (Fig 4B). Afterward, the shaver is again inserted with the objective of depicting the lesion and completing the surrounding soft-tissue dissection (Table 1).

Table 1.

Key Points

The patient is placed in the supine position without traction.

Conventional hip arthroscopy portal (AL and PALA) placement is performed, aiming straightforward to the calcific bone, under fluoroscopic control.

Resection of the surrounding soft tissue with a shaver and radiofrequency device is mandatory to define the limits of the calcific tendon.

Bone resection is performed with a 5-mm round burr.

AL, anterolateral portal; PALA, proximal accessory portal.

Once the extension of the lesion is established, the bone lesion is resected with a 5-mm round burr (Arthrex) (Fig 5 A and C). To perform complete resection of a calcific lesion, it is convenient to switch the burr's portal placement by using an open metal cannula (Fig 5B). The arthroscope is now inserted in the proximal portal, leaving the burr in the distal or anterolateral portal, to complete the resection from the distal aspect of the lesion (Table 2). Lastly, new fluoroscopic images in the anteroposterior and lateral views are recommended to assess the whole lesion resection. The specimen is submitted for pathologic examination, and the presence of hydroxyapatite crystals is confirmed.

Fig 5.

After the full extension of the lesion has been established, the bone lesion is resected with a 5-mm round burr, switching the portal placement to facilitate the whole lesion resection. (A) Anteroposterior fluoroscopic image with bone resection in progress with 5-mm burr, (B) clinical photograph showing portal switch, and (C) endoscopic view showing lesion resection with 5-mm burr. The asterisk depicts the bone calcific lesion.

Table 2.

Tips and Pearls to Ensure Whole Lesion Resection

The surgeon begins the resection once the lesion has been fully identified.

Switching portal placement is useful to facilitate defining the limits of the whole lesion.

The surgeon performs the resection from the lesion's distal aspect, pointing to the reflected head footprint of the rectus femoris at the ilium above the acetabulum.

Intraoperative fluoroscopic control in the AP and lateral views is essential during the procedure.

AP, anteroposterior.

In our rehabilitation protocol, patients are mobilized the first day after surgery.¹⁶ All patients receive heterotopic ossification prophylaxis after the procedure, with 500 mg of naproxen twice a day for 3 weeks starting within 24 hours after surgery¹³ (Table 3).

Table 3.

Tips to Avoid Complications

Lateral portal placement in the hip safe zones under fluoroscopic control minimizes neurovascular risks.

The surgeon should follow the tips to perform the whole resection with accuracy.

Gentle soft-tissue management is recommended to avoid calcific lesion recurrence.

Patients should follow an early rehabilitation protocol including joint mobilization.

Patients should receive heterotopic ossification prophylaxis after the procedure.

Discussion

Calcific tendinitis can be classified as acute or chronic. The acute phase, in which spontaneous resolution usually occurs in less than 2 weeks, is characterized by prompt onset of localized pain and limited range of joint motion and, sometimes, by erythema, warmth, and tenderness over the affected area. In chronic cases, mild or moderate pain and the aforementioned symptoms may persist for 2 to 24 months.⁴

Calcific tendinitis has been reported in many anatomic regions, the shoulder being the most frequently affected.6, 17 The hip region is also a common location, although the rectus femoris muscle is rarely affected.12, 14 The rectus femoris has a straight head that originates from the anterior inferior iliac spine and a reflected head that originates at the ilium above the acetabulum.⁸ The reflected head is more commonly affected by calcific tendinitis than the straight head.6, 18 Other conditions in the differential diagnosis of calcification in the region of the rectus femoris include avulsion fracture, os acetabula, sesamoid bones in the tendon of the rectus femoris, and myositis ossificans.⁶ The diagnosis is based on the clinical picture (pain, tenderness, and warmth over the upper lateral thigh and anterior inferior iliac spine; a positive Ely test; limited hip movements; and functional disability) as well as typical radiographic findings.⁴ If diagnostic uncertainty is present, advanced imaging techniques such as bone scintigraphy, ultrasonography, computed tomography, or magnetic resonance imaging should be performed.¹⁹

Although in most cases CTRF is a self-limited disease, some patients with mild to severe discomfort or painful chronic cases do need treatment. Treatment options include conservative measures, such as nonsteroidal anti-inflammatory drugs¹¹ or extracorporeal shock wave therapy,¹² and more invasive measures, such as local steroid or anesthetic injections,6, 8 open surgical removal,10, 11 or endoscopic removal.7, 14, 15 Typically, with conservative therapy, most patients recount early and complete relief; however, some refractory cases require further treatment. In these circumstances endoscopic resection provides a minimally invasive technique for removal of intractable CTRF, presenting the benefits of potentially earlier recovery compared with open surgery. In addition, because calcific tendinitis is an extra-articular lesion, traction is not required during the procedure, avoiding complications such as neurapraxia.⁷

To our knowledge, there have been 3 reports of endoscopic treatment of calcific tendinitis around the hip.7, 14, 15 In the first report, by Kandemir et al.,¹⁴ the gluteus medius and minimus of the peritrochanteric space were the sites involved. In the second report, Yang and Oh⁷ described a patient with intractable calcific tendinitis of the deep portion of the rectus femoris. Recently, Peng et al.¹⁵ reported satisfactory and effective arthroscopic treatment of 3 patients with chronically painful calcific tendinitis in the reflected head of the rectus femoris. Because our surgical technique is an entirely extra-articular procedure, we avoid performing incisions in the hip capsule fibers, which may prevent subsequent tissue retraction or instability.

We describe a simple technique to access the periarticular hip region. We use 2 portals, the anterolateral portal and the proximal accessory portal, whose use has been described to perform conventional hip arthroscopy, as well as to perform an endoscopic approach to greater trochanter disorders. Robertson and Kelly²⁰ established a safe zone to access the hip joint. They evaluated hip arthroscopy portals in cadaveric specimens and showed that 11 arthroscopic portals can be safely inserted into the central, peripheral, and peritrochanteric compartments of the hip. The 2 portals that we use in our technique are placed in the lateral aspect of the hip. According to the aforementioned “safe zones,” the lateral location of such portals seems to provide substantial benefits avoiding neurovascular structures. Another concern in the application of our technique could be the amount of muscle removal required to depict the calcific lesion. Nevertheless, we have found that a minimal amount of soft-tissue removal generates the sufficient space around the lesion necessary to resect the whole lesion. In every case gentle management of soft issue is recommended.

First-line treatment of calcific tendinitis should always be conservative.⁶ Nevertheless, despite the self-limiting nature of calcific tendinitis, pain may persist in some cases and further treatment should be performed. Given our good experience with hip arthroscopy in relatively young and active patients with labral tears or femoroacetabular impingement, as well as other hip pathologies, we have found endoscopic removal of CTRF to be a valuable option because of its low morbidity and rapid recovery.

Endoscopic treatment of calcific tendinitis of the hip is a valuable technique in the treatment of patients who do not respond to conservative treatment. This article and Video 1 have described our preferred technique for arthroscopic treatment of calcific tendinitis of the hip.

Supplementary Data

Video 1

Arthroscopic technique for calcific tendinitis resection of rectus femoris.