EP7.20 Open Anterior Inferior Iliac Spine Exostectomy and Rectus Femoris Repair for the Treatment of Chronic Subspine Impingement – A Case Report

Abstract Introduction Subspine impingement is an increasingly recognized extra-articular cause of hip pain, often related to abnormal morphology of the anterior inferior iliac spine (AIIS). Chronic AIIS avulsion injuries in adolescent athletes may heal with malunion or ossification, leading to persistent bony prominence, mechanical impingement, and associated rectus femoris pathology. While arthroscopic decompression is commonly utilized, substantial deformity or tendon compromise may necessitate an open approach. Case Presentation A 16-year-old male soccer athlete presented with chronic right proximal quadriceps pain and recurrent injury, refractory to prolonged nonoperative management. He sustained an acute-on-chronic exacerbation while kicking and was unable to return to sport. Imaging demonstrated a prominent AIIS consistent with chronic avulsion malunion, with CT confirming osseous deformity and MRI revealing edema and partial tearing of the proximal rectus femoris origin. Given the degree of bony overgrowth and tendon pathology, the patient underwent open AIIS decompression and rectus femoris repair. Through a longitudinal approach centered over the AIIS, the rectus femoris direct head was identified, noted to be thickened and tendinopathic, and sharply elevated from its origin. Fluoroscopic guidance was used to perform an AIIS exostectomy with an osteotome, ensuring adequate decompression while avoiding articular violation. The bony surface was contoured to eliminate impingement. The rectus femoris tendon was mobilized and repaired anatomically using multiple knotless suture anchors placed into the prepared AIIS footprint, with sutures passed in horizontal mattress configuration and sequentially tensioned to achieve a stable, anatomic repair. Postoperatively, the patient progressed through protected weightbearing and activity restrictions. At 2-month follow-up, he demonstrated radiographic evidence of adequate decompression, complete pain resolution, and appropriate rehabilitation progression. Discussion Although arthroscopic AIIS decompression yields favorable outcomes, resection greater than 10 mm risks compromising the rectus femoris origin. In cases with significant deformity or pre-existing tendon injury, an open approach allows for controlled resection and reliable tendon repair. Conclusion Open AIIS decompression with rectus femoris repair is a valuable option in subspine impingement with substantial deformity and tendon pathology, enabling effective decompression while restoring hip flexor integrity.