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.

History

Patients with trochanteric bursitis are typically middle aged, although the condition can also be seen in younger athletes, most often in young runners. The incidence is higher among females. The pain is characteristically located directly over the greater trochanter, with occasional radiation to the lateral thigh and buttocks. A select number of individuals may report a history of traumatic onset, but it is more commonly associated with repetitive microtrauma. Patients often complain of being unable to lie on the affected side because of the direct painful compression of the bursa. As a result of the sensation of the ITB sliding over the greater trochanter (which is often audible) with repeated hip flexion and extension, individuals with concurrent external snapping hip often state that they can dislocate the hip.

Physical examination

Tenderness to palpation over the greater trochanter is invariably present. Pain elicited with deep palpation over the greater trochanter when the affected hip is up and adducted with the patient in the lateral decubitus position is known as the Little sign. Pain is commonly elicited with active abduction and passive adduction of the hip. Patients may demonstrate a positive Ober test because of increased tension in the ITB. A response to a local injection in the bursa can be diagnostic as well as therapeutic. Individuals with an associated snapping ITB can often reproduce the snapping in the office, such as that which occurs with a running motion. Hip flexion flips the thickened posterior portion of the ITB anteriorly over the greater trochanter, and hip extension brings the affected ITB posteriorly over the trochanter; these movements are accompanied by an audible, palpable snapping sensation.

Imaging and diagnostic studies

The diagnosis of trochanteric bursitis is a clinical one. Plain radiographs of the hip and pelvis are primarily used to rule out other disorders, but they may also reveal calcifications around the greater trochanter in 20% to 40% of patients. Coxa vara has been reported to be a predisposing anatomic factor among patients with external snapping hip. Although magnetic resonance imaging of the hip is not necessary for the diagnosis, it can show bursal inflammation and increased signal in the tendinous attachments to the greater trochanter. Plain radiographs and magnetic resonance imaging are useful primarily as exclusionary tools.

Indications

Operative intervention is indicated for the following patients:

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.

Figure 16–1 The patient is positioned in the lateral decubitus position, with the entire hip and leg draped free.

Figure 16–2 The 4-mm, 30-degree arthroscope and 4.5-mm, full-radius shaver are inserted into the proximal and distal portals, respectively, in the subcutaneous tissues overlying the iliotibial band.

Figure 16–3 The fat overlying the ITB is removed to allow for the visualization of the iliotibial band. The localizing needle is seen at the top of the photograph.

After the ITB is clearly identified, the arthroscopic ablator is used to create a longitudinal incision approximately 7 cm to 8 cm in length in line with the fibers of the ITB just slightly posterior to its midline and the trochanteric prominence; this exposes the trochanteric bursa (Figure 16-4). The surgical assistant abducts the leg to further relax the incised ITB (Figure 16-5) and to allow the surgeon to advance the arthroscope and instruments underneath the ITB. Next, the shaver and the ablator are used to thoroughly debride the bursa and its thick, fibrous adhesions. Having the assistant slowly internally and externally rotate the leg brings the posterior and anterior portions of the bursa, respectively, into view. Extreme internal rotation is avoided, because this maneuver places the posteriorly located sciatic nerve at risk. Coagulation is frequently necessary to maintain hemostasis and visualization.

Figure 16–4 To gain access to the bursa, the ablator is used to create a longitudinal incision in the iliotibial band just slightly posterior to the midline.

Figure 16–5 A, The assistant abducts the leg to relax the iliotibial band. B, With the use of the ablator, the surgeon debrides the bursa and its dense adhesions.

After the bursa has been completely excised, the tendinous attachments of the gluteus minimus and the gluteus medius to the greater trochanter can be seen. Occasionally, irritation and scuffing of the tendinous insertions are noted, and, infrequently, tears and avulsions of the tendons (so-called rotator cuff tears of the hip) are present (Figure 16-6). Early in our experience, we treated the tears with gentle debridement, but, more recently, we have repaired these tears with nonabsorbable sutures with the use of a technique that is similar to the marginal convergence repair technique used for rotator cuff tears in the shoulder. After bursal excision has been completed and hemostasis is ensured, the instruments are withdrawn, and excess fluid is expressed from the portals. The portals are then closed with nylon suture, and a compression dressing and ice pack are applied.

Figure 16–6 A tear of the tendinous insertion of the abductor muscle.

In patients with associated external coxa saltans, an ITB lengthening procedure is necessary in addition to the standard trochanteric bursectomy. After the usual slightly posterior longitudinal incision is made in the ITB, the arthroscopic ablator is used to gently resect its anterior and posterior edges. Additional tissue is removed near the center of the midline cut to create an elliptical resection of the ITB (Figure 16-7). The posterior resection is slightly greater than the anterior resection, because the snapping usually results from the thickened posterior portion of the ITB flipping over the greater trochanter. An alternative method is to perform a crisscross secondary transverse incision, thereby effectively creating a cruciate-type release. The hip is taken through a range of motion to ensure adequate decompression and resection. The bursa is then resected as previously described.

Figure 16–7 An elliptical resection of the iliotibial band has been performed for the correction of external coxa saltans.

Postoperative rehabilitation

All of these surgeries are performed on an outpatient basis. Patients are allowed to be weight bearing as tolerated with the assistance of crutches or a walker. The first postoperative visit is at 48 to 72 hours after surgery. If patients exhibit an independent gait at that time, the assistive devices are discontinued. Sutures are removed 2 to 5 days after surgery, and the wounds are checked for excessive bleeding or swelling. Physical therapy is then begun to strengthen the hip musculature and to ensure the restoration of the full range of motion.

Because trochanteric bursitis can be caused by an abnormal gait, weakness of the hip flexors, or chronic low back pain, emphasis should be placed on correcting the cause of the problem. After the immediate postoperative regimen has been completed, attention should be focused on increasing the flexibility of the lumbar spine and correcting any weakness of the hip abductors.

Results and outcomes

In general, both open and arthroscopic treatments of trochanteric bursitis result in a high percentage of good outcomes (Table 16-1). Physicians agree that, in the majority of patients with this condition, a conservative approach will be successful; only a select few patients will require operative intervention. For a successful result in patients with external coxa saltans, the ITB should be effectively lengthened by one of several open or arthroscopic methods, such as a Z-plasty, an ellipsoidal-shaped or diamond-shaped resection, a cruciate or cross-shaped incision, or a simple longitudinal release.

Complications

In the senior author’s published series of 25 patients with refractory trochanteric bursitis who were treated with arthroscopic bursectomy and longitudinal ITB release, 1 patient developed a seroma that required an operative incision and drainage, and 1 patient continued to have postoperative pain and was treated with an open bursectomy that resulted in the successful resolution of symptoms. The most frequently reported complication in the literature has been the incomplete relief of symptoms after operative intervention. This can be minimized with an accurate preoperative diagnosis, a thorough bursectomy, and a candid discussion with the patient regarding realistic expectations. The majority of patients have preexisting altered lower limb biomechanics and comorbidities that may preclude complete relief. In the patient with external coxa saltans, pain and snapping are typically relieved with lengthening of the ITB and bursectomy. Residual painless snapping is not uncommon and requires no further operative treatment.