Arthroscopic Iliotibial Band Lengthening and Bursectomy for Recalcitrant Trochanteric Bursitis and Coxa Saltans Externa

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CHAPTER 16 Arthroscopic Iliotibial Band Lengthening and Bursectomy for Recalcitrant Trochanteric Bursitis and Coxa Saltans Externa

Introduction

Pain over the lateral aspect of the hip can be attributed to a number of conditions. The differential diagnosis includes degenerative joint disease of the hip, avascular necrosis of the femoral head, stress fracture of the femoral neck, infection, entrapment neuropathies, referred pain from lumbar disc disease, sciatica, snapping hip, and trochanteric bursitis. Trochanteric bursitis is a very common condition that is treated by both orthopedic surgeons and general practitioners and can be a source of disabling lateral hip pain. A dull, intermittent, aching pain in the region of the greater trochanter characterizes the condition. Occasionally, the pain radiates to the lateral thigh or the buttocks. The condition is thought to be a result of repetitive microtrauma and friction between the iliotibial band (ITB) and the greater trochanter, with subsequent inflammation of the interposed bursa. Degeneration of the gluteal tendons at the trochanteric attachment can also occur.

Some patients present with complaints of pain and an audible snapping sensation near the lateral aspect of the hip. External snapping hip or coxa saltans is caused by a tight ITB sliding over the greater trochanter with repetitive flexion and extension of the hip. The condition must be differentiated from an internal snapping hip, which is commonly attributed to the sliding of the iliopsoas tendon over the femoral head or the iliopectineal eminence, and from intra-articular causes of snapping hip, such as loose bodies, labral tears, and synovial chondromatosis. Asymptomatic external coxa saltans does not require treatment, but occasionally patients develop associated trochanteric bursitis with resultant pain and disability.

Most patients with trochanteric bursitis respond to nonoperative treatment that typically consists of activity modification, nonsteroidal anti-inflammatory medications, the stretching of a tight ITB, physical therapy with modalities (e.g., heat, ultrasound), and local injections of corticosteroids and anesthetics directly into the bursa. For the small group of patients whose symptoms fail to resolve with nonoperative therapy, the excision of the trochanteric bursa is recommended. Historically, this procedure has been performed with the use of an open approach; however, several authors have recently reported similar success when performing the bursectomy arthroscopically. In patients who have a tight ITB and associated external snapping hip, an ITB lengthening should be performed concurrently with the bursectomy.

Surgical technique

Our preferred surgical technique for recalcitrant trochanteric bursitis is an arthroscopic trochanteric bursectomy. Patients are positioned in the lateral decubitus position with the affected extremity facing up. A deflatable beanbag is used to stabilize the patient, and all bony prominences are well padded. The leg is draped freely so that the hip can be taken through a full range of motion (Figure 16-1). The greater trochanter is palpated and outlined on the skin with a marker. A spinal needle is then inserted directly onto the trochanteric prominence. The needle is then withdrawn slightly by several millimeters, and approximately 30 mL to 40 mL of normal saline is injected into the bursa, thus creating a space underneath the ITB. We prefer to leave the needle in for the purpose of localization. Next, a proximal portal is created 2 cm to 3 cm proximal to the trochanter, and a distal portal is created 2 cm to 3 cm distal to the trochanter. The skin is incised in line with the long axis of the femur. A 4-mm, 30-degree arthroscope is introduced directly into the subcutaneous tissues above the ITB. A 4.5-mm shaver is placed in the other portal and localized to the arthroscope with a triangulation technique (Figure 16-2). The fat directly above the ITB is removed to allow for full visualization of the ITB (Figure 16-3). An arthroscopic ablation probe can also be used to maintain hemostasis and concurrently to remove adherent tissues.

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