The Indirect Head of the Rectus Femoris as a Variable Surgical Landmark in Hip Arthroscopy: A Review of Surgical Access, Capsulotomy, Iatrogenic Injury and Reconstruction

Background: The indirect head of the rectus femoris (IHRF) occupies a surgically important position within the anterior pericapsular region of the hip and is increasingly used as a landmark during arthroscopic capsular access. Purpose: To synthesize current evidence regarding the role of the IHRF in hip arthroscopy, focusing on surgical access, iatrogenic injury, tendon protection, acetabular exposure, anatomical variability and reconstruction. Methods: This structured narrative review incorporated a literature search of PubMed, Scopus and Web of Science Core Collection using complementary approaches addressing IHRF anatomy, hip arthroscopy, capsulotomy, pericapsular relationships, iatrogenic injury, imaging and reconstruction. The searches yielded 22,200 records, of which 13,058 were unique after removal of 9142 duplicates. The evidence was synthesised qualitatively because of substantial methodological and clinical heterogeneity. Results: The IHRF has been described as an intraoperative landmark during longitudinal and outside-in capsulotomy. Cadaveric evidence documents tendon violation during capsular access, and an intraoperative IHRF injury has also been reported in a clinical cohort; however, comparative clinical evidence concerning IHRF-specific safety remains insufficient. Technical studies also indicate that the tendon may interfere with anterosuperior acetabular exposure. Anatomical studies demonstrate frequent superior and inferior aponeurotic expansions and substantial variation in proximal tendon morphology. However, the identified surgical literature has not evaluated capsulotomy safety or operative outcomes according to these configurations. The IHRF has also been used as a local graft for acetabular labral reconstruction and incorporated into capsular reconstructive techniques. Conclusions: The IHRF is both a useful surgical landmark and an anatomically variable structure at risk during hip arthroscopy. Whether morphological variability has clinically meaningful consequences for surgical access, tendon protection and reconstructive use remains unresolved.