Trochanteric Bursitis Following Primary Total Hip Arthroplasty: Incidence, Predictors, and Treatment

Risk Factors for Trochanteric Bursitis Following Total Hip Arthroplasty: A Radiographic Analysis

BACKGROUND

Trochanteric bursitis (TB) is a prevalent complication following total hip arthroplasty (THA), with increased offset hypothesized as a potential risk factor. This study investigated potential TB predictors in THA patients, including radiographic measurements of offset and leg length, comorbidities, and patient characteristics.

METHODS

In this retrospective cohort study, all THA patients from a single academic tertiary care center between 2005 and 2021 were reviewed. Exclusion criteria included less than one-year follow-up, osteonecrosis, or fracture. Manual radiographic measurements of offset (acetabular, femoral, and total) and leg length from preoperative and postoperative antero-posterior pelvis X-rays were taken, with scaling using femoral cortical diameter. Univariable and multivariable Cox proportional hazard models were employed to estimate TB risk.

RESULTS

Of 1,094 patients, 103 (9.4%) developed TB, with a median (Q1, Q3) time to presentation of 41.8 weeks (25.5, 66.9). In univariable models, only sex was associated with increased TB risk, with women exhibiting a 1.79 times increased risk (hazard ratio: 1.79 (1.16, 2.76), P = .009). Changes in acetabular offset, femoral offset, total offset, and leg length between preoperative and postoperative radiographs were not associated with an increased risk of developing TB in the univariate or multivariate models. Furthermore, various offset thresholds were evaluated, with no amount of increased offset showing increased TB risk.

CONCLUSIONS

This study found no relationship between femoral, acetabular, or total offset and TB following THA. These findings suggest that surgeons may consider adding offset for increased prosthetic stability in high-risk cases. However, given that this is a retrospective study, the authors are not advocating for the routine use of increased offset. The study identified women as a risk factor with a 1.79 times higher TB risk, highlighting the importance of counseling women patients on this heightened risk.

Offset Considerations in Total Hip Arthroplasty

To perform total hip arthroplasty (THA) successfully, a surgeon must be able to place the implants in a position that will restore and duplicate the patient's baseline anatomy and soft-tissue tension. One of the critical factors is the restoration of femoral offset. It is the goal of this review to precisely define measurement of offset in THA, describe its role in hip joint biomechanics, outline alterations that can be performed intraoperatively, and explain how it can create potential pathologic states. If there is a lack of offset restoration, it can result in a host of complications, including bony impingement with pain, edge loading or prosthetic joint instability, and alterations in the muscle length-tension relationship leading to reduced motor performance. Excessive femoral offset can increase hip abductor muscle and iliotibial band tension resulting in greater trochanteric pain regardless of the surgical approach. The purpose of this review was to analyze intraoperative surgical factors, choice of prosthetic implant type and position that are required to maximize stability, and dynamic motor performance after THA.

An Unconventional Solution for Persistent Lateral Hip Prosthetic Friction Syndrome (LHPFS) after Revision Total Hip Arthroplasty

We report on a 77-year-old male patient, who presented with excessive bone loss at the area of the greater trochanter after several hip revision surgeries resulting in a persistent friction syndrome caused directly by the rough surface and sharp edges of the prosthetic shoulder of a well-fixed Wagner-type revision stem. Surgery was performed by creating a cemented neotrochanter with an attached polyester patch around the proximal lateral shaft and performing a Z-plasty of the iliotibial tract. Twelve months postoperatively, the patient reported a reduction in subjective pain of 50% and improvement of the Harris Hip Score from 45 to 75 points. Without a definition in the current literature, the authors propose the term "lateral hip prosthetic friction syndrome" (LHPFS) to describe this medical condition.

Unrepaired Trochanteric Bursae as a Risk Factor for Deep Gluteal Syndrome After Total Hip Arthroplasty: A Prospective Randomized Controlled Trial

BACKGROUND

The trochanteric bursae are often left unrepaired after total hip arthroplasty (THA) and they retract posteriorly over the muscle belly of the piriformis. Deep gluteal syndrome (DGS) is a multifactorial condition presenting as buttock pain and is attributed to nondiscogenic sciatic nerve irritation or impingement causes. The purpose of this study was to investigate the relationship between bursal repair and incidence of DGS in patients undergoing THA.

METHODS

This prospective randomized trial included patients treated with a THA between January and December 2022 for a diagnosis of primary osteoarthritis. Patients were randomized into 2 groups: group 1 underwent a routine bursal repair, while group 2 did not, leaving the bursae unrepaired. Follow-up was performed on the 15th, 30th, and 90th day postoperatively with clinical scores, physical examinations, and laboratory tests. In this cohort of 104 patients, mean age was 55 years (range, 26 to 88). Demographic variables as well as range of motion and overall clinical results showed no significant difference between the groups.

RESULTS

DGS rates were significantly more common in the patients who had an unrepaired bursa (group 2) both on the 30th and 90th postoperative days, while comparison of lateral trochanteric pain on palpation showed similar results between the groups.

CONCLUSIONS

DGS is common in individuals who have unrepaired trochanteric bursal tissue following a THA. Despite its higher frequency, these symptoms did not have a substantial impact on the overall clinical scores, which remained consistent across the study groups.

Management of Greater Trochanteric Pain Syndrome After Total Hip Arthroplasty: Practice Patterns and Surgeon Attitudes

INTRODUCTION

Greater trochanteric pain syndrome (GTPS) or trochanteric bursitis is described as pain on the lateral side of the hip that does not involve the hip joint and can be elicited clinically by palpation over the greater trochanter. To date, there remains no consensus on clinical guidelines for either diagnosis or management of GTPS.

METHODS

To understand the practice patterns, beliefs, and attitudes relating to the management of GTPS after total hip arthroplasty, a survey was developed and completed by Canadian arthroplasty surgeons. The final survey consisted of 23 questions divided into three sections: 1) screening questions; 2) demographic information; and 3) practice patterns, attitudes, and beliefs.

RESULTS

Most surgeons use physical examination alone for diagnosis. A detailed analysis indicates that surgeons primarily treat GTPS with oral anti-inflammatories (57.1%), structured physiotherapy (52.4%), and steroid injections (45.2%). Management options are typically nonsurgical and comprise a combination of either unstructured or targeted physiotherapy, corticosteroid injections, or platelet-rich plasma.

DISCUSSION

There remains an absence of clinical consensus for the diagnosis and management of GTPS after total hip arthroplasty. Physical examination is most often relied on, regardless of the availability of imaging aids. While common treatments of GTPS were identified, up to one-third of patients fail initial therapy.

Psychometric Characteristics, Cross-Cultural Adaptation and Validation of the Slovenian Version of the Victorian Institute of Sports Assessments for Gluteal Tendinopathy Questionnaire (VISA-G)

Introduction

Greater trochanteric pain syndrome (GTPS) denotes several disorders around the lateral aspect of the hip. GTPS may develop in native hips as well as after total hip arthroplasty (THA). It is estimated that 5-12% of patients suffer from GTPS after primary THA. Despite the prevalence of GTPS, it is hard to diagnose and manage it properly. The VISA-G questionnaire was developed as a patient-reported outcome measurement tool for evaluation of GTPS. The aims of the present study were to evaluate the reliability of the VISA-G Slovenian and its construct and criterion validity.

Methods

After the finalization of the VISA-G Slovenian translation procedure, 59 patients with a painful trochanteric region planned for THA filled in the VISA-G Slovenian at the hospital on two occasions 5-7 days apart. On the first occasion, each patient also filled in the EQ-5D-5L questionnaire and the Harris Hip Score (HHS) was completed by the physiotherapist.

Results

The VISA-G Slovenian was found to have a test-retest reliability of ICC 0.977; 95% CI [0.96; 0.986]. Internal consistency was assessed with Cronbach's alpha 0.79. The statistically significant, but low, correlation between the HHS and VISA-G (r=0.48) was obtained. Concurrent validity of the VISA-G with the EQ-5D-5L showed moderate to strong correlations in Mobility, Self-Care, Usual Activities, Pain, EQ-5D-5L Index and EQ VAS, but low correlation in the Anxiety subscale. No floor and ceiling effect were obtained.

Conclusions

The VISA-G Slovenian has excellent psychometric properties needed to measure gluteal tendinopathy-related disability of patients in Slovenia. Thus, we recommend using the questionnaire for measuring trochanteric hip pain.

ACR Appropriateness Criteria® Imaging After Total Hip Arthroplasty

This article reviews evidence for performing various imaging studies in patients with total hip prostheses. Routine follow-up is generally performed with radiography. Radiographs are also usually the initial imaging modality for patients with symptoms related to the prosthesis. Following acute injury with pain, noncontrast CT may add information to radiographic examination regarding the presence and location of a fracture, component stability, and bone stock. Image-guided joint aspiration, noncontrast MRI, and white blood cell scan and sulfur colloid scan of the hip, are usually appropriate studies for patients suspected of having periprosthetic infection. For evaluation of component loosening, wear, and/or osteolysis, noncontrast CT or MRI are usually appropriate studies. Noncontrast MRI is usually appropriate for identifying adverse reaction to metal debris related to metal-on-metal articulations. For assessing patients after hip arthroplasty, who have trochanteric pain and nondiagnostic radiographs, ultrasound, or MRI are usually appropriate studies. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Excision of trochanteric bursa during total hip replacement: Does it reduce the incidence of post-operative trochanteric bursitis?

BACKGROUND

Trochanteric bursitis is a common complication following total hip replacement (THR), and it is associated with high level of disability and poor quality of life. Excision of the trochanteric bursa prophylactically during THR could reduce the occurrence of post-operative trochanteric bursitis.

AIM

To evaluate whether synchronous trochanteric bursectomy at the time of THR affects the incidence of post-operative trochanteric bursitis.

METHODS

This retrospective cohort study was conducted in the secondary care setting at a large district general hospital. Between January 2010 and December 2020, 954 patients underwent elective primary THR by two contemporary arthroplasty surgeons, one excising the bursa and the other not (at the time of THR). All patients received the same post-operative rehabilitation and were followed up for 1 year. We reviewed all cases of trochanteric bursitis over this 11-year period to determine the incidence of post-THR bursitis. Two proportion Z-test was used to compare incidences of trochanteric bursitis between groups.

RESULTS

554 patients underwent synchronous trochanteric bursectomy at the time of THR whereas 400 patients did not. A total of 5 patients (incidence 0.5%) developed trochanteric bursitis following THR; 4 of whom had undergone bursectomy as part of their surgical approach, 1 who had not. There was no statistically significant difference between the two groups (Z value 1.00, 95%CI: -0.4% to 1.3%, P = 0.32). There were also 8 other patients who had both trochanteric bursitis and hip osteoarthritis prior to their THR; all of whom were treated with THR and synchronous trochanteric bursectomy, and 7 had resolution of their lateral buttock pains but 1 did not.

CONCLUSION

Synchronous trochanteric bursectomy during THR does not materially affect the incidence of post-operative bursitis. However, it is successful at treating patients with known trochanteric bursitis and osteoarthritis requiring THR.

Incidence of and Risk Factors for Lateral Trochanteric Pain After Direct Anterior Approach Total Hip Arthroplasty

Lateral trochanteric pain (LTP) is a common complication after total hip arthroplasty (THA). The goals of this study were to report the incidence of LTP after direct anterior approach (DAA) THA, describe the treatment course and outcomes, and examine patient-specific and implant-related potential risk factors. A retrospective review identified patients who underwent primary DAA THA with at least 1-year follow-up. Postoperative functional outcome scores and LTP occurrence were recorded. Patient demographics, surgical indications, implant characteristics, medical comorbidities, and radiographic parameters were obtained. Logistic regression analysis was used to identify risk factors. A total of 610 THA procedures were performed for 563 patients (mean follow-up, 30.9±15.2 months). The overall incidence of LTP was 11.6%. All cases of LTP were successfully treated conservatively, although these patients, compared with patients who did not have postoperative LTP, experienced significantly lower functional outcome scores (Harris Hip Score, 96.6±4.7 [range, 55-100] vs 89.9±8.5 [range, 42-100], respectively; P<.001). Logistic regression analysis identified female sex (odds ratio, 2.30; 95% CI, 1.32-4.02), diabetes mellitus (odds ratio, 2.32; 95% CI, 1.11-4.88), hypertension (odds ratio, 1.94; 95% CI, 1.15-3.28), and the use of an offset acetabular liner (odds ratio, 2.50; 95% CI, 1.06-5.91) as independent risk factors for LTP. There was no correlation between LTP and radiographic parameters. The incidence of LTP after DAA THA is similar to reported rates for other THA surgical approaches. Female sex, medical comorbidities, and the use of offset acetabular liners are likely associated, and patients should be counseled appropriately. Postoperative LTP results in worse functional outcomes, although all cases can be treated conservatively. [Orthopedics. 2022;45(2):e79-e85.].

Greater trochanteric pain after primary total hip replacement, comparing the anterior and posterior approach: A secondary analysis of a randomized trial

BACKGROUND

Greater trochanteric pain (GTP) after total hip replacement is a common cause of residual lateral hip pain, regardless of the approach used. The goal of our study was to evaluate GTP after a direct anterior approach (DAA) compared to a posterior approach (PA) as well as the clinical outcomes of both approaches and answer the following: 1) What is the incidence of trochanteric pain after primary THA with two different surgical approaches? 2) What is the functional outcome of patients with GTP? 3) What proportion of patients with GTP resort to peritrochanteric injections?

HYPOTHESIS

Our hypothesis is that GTP is present with both approaches but satisfaction is lower with the PA.

PATIENTS AND METHODS

A secondary analysis of a previously published clinical trial with 55 total hip arthroplasty patients randomized in one of two surgical approaches: 27 patients underwent the anterior modified Hueter approach, while the other group of 28 patients were operated using the posterior approach. Study outcomes were Modified Harris Hip Score (MHHS), satisfaction score, pain when lying on the affected side, and requiring an injection. Hip offset, femur lateralization and leg lengthening were measured before and after surgery.

RESULTS

Forty-five patients were available for complete follow-up at a mean of 62 months (range: 48-74). The incidence of GTP was higher in the posterior approach [PA: 6/21 (29%) vs DAA 4/24 (17%)) (p=0.3). Patients operated through a PA experienced more pain [5/21 (24%) of patients; VAS=mean 5.3] when lying on their operated side, compared to DAA patients [2/24 (8%) of patients; VAS=mean 2) (p=0.2)]. However, MHHS, patient satisfaction with surgery, radiological assessment for hip offset, femur lateralization or leg lengthening, and injections required were similar for both approaches. Overall, satisfaction and functional outcome with surgery was significantly lower in GTP patients, regardless of the approach.

CONCLUSIONS

GTP impacts patient satisfaction and functional outcome in total hip arthroplasty patients. PA patients reported more trochanteric pain than DAA patients, which affected their clinical outcome.

LEVEL OF EVIDENCE

III.

Minimizing complications in bikini incision direct anterior approach total hip arthroplasty: A single surgeon series of 865 cases

PURPOSE

The purpose of this study was to report all complications during the first consecutive 865 cases of bikini incision direct anterior approach (DAA) total hip arthroplasty (THA) performed by a single surgeon. The secondary aims of the study are to report our clinical outcomes and implant survivorship. We discuss our surgical technique to minimize complication rates during the procedure.

METHODS

We undertook a retrospective analysis of our complications, clinical outcomes and implant survivorship of 865 DAA THA's over a period of 6 years (mean = 3.9yrs from 0.9 to 6.8 years).

RESULTS

The complication rates identified in this study were low. Medium term survival at minimum 2-year survival and revision as the end point, was 99.53% and 99.84% for the stem and acetabular components respectively. Womac score improved from 49 (range 40-58) preoperatively to 3.5(range 0-8.8) and similarly, HHS scores improved from 53(range 40-56) to 92.5(range 63-100) at final follow-up (mean = 3.9 yrs) when compared to preoperative scores.

CONCLUSIONS

These results suggest that bikini incision DAA technique can be safely utilised to perform THA.

Lateral Trochanteric Pain Following Primary Total Hip Arthroplasty: Incidence and Success of Nonoperative Treatment

BACKGROUND

Our study aimed at quantifying the overall incidence of lateral trochanteric pain (LTP) following total hip arthroplasty (THA) and risk based on surgical approach. The success of conservative treatment and potential risk factors for failure of conservative treatment were evaluated.

METHODS

This is a retrospective review of patients who underwent primary THA between 2010 and 2019 and had a postoperative diagnosis of ipsilateral LTP. Chart review revealed patient demographics/comorbidities, preoperative diagnosis, surgical approach, femoral components, and nonoperative treatment modalities. Radiographic analysis was performed to measure leg length discrepancy, femoral offset, and femoral head lateralization.

RESULTS

The incidence of LTP following primary THA was 1.70% (573/33,761) with an average time to diagnosis of 27.3 months. The direct anterior approach demonstrated the highest risk and the direct lateral demonstrated the lowest risk for LTP (P < .001). Also, 82.4% (472/573) were diagnosed greater than 6 months postoperatively (P < .001). Of 573 patients, 95 (16.6%) were treated with physical therapy, home exercises, or oral medications with a success rate of 96.8% (92/95). Remaining 478 (83.4%) were treated with corticosteroid injection (CSI). And 89.5% (428/478) of the CSI cohort demonstrated clinical improvement with 3 or less CSIs. Risk factors for failure of conservative treatment were depression (P = .034), kidney disease (P = .040), and osteoporosis (P = .007).

CONCLUSION

Postoperative LTP after THA is rare with an incidence of 1.70%. The direct anterior approach presented higher risk of LTP. Non-CSI modalities and CSIs were both successful treatment options. In patients with depression, kidney disease, and osteoporosis, conservative treatment may be less efficacious.

Changes in femoral offset is not associated with increased incidence of lateral hip pain following total hip arthroplasty

PURPOSE

Increased femoral offset following total hip arthroplasty allows for greater stability of the hip joint. However, the increase in femoral offset can cause an impingement of local structures resulting in persistent lateral hip pain. There is conflicting evidence whether changes in femoral offset increases the rates of lateral hip pain following total hip arthroplasty.

METHODS

This was a retrospective case control study that grouped patients based on the presence of persistent lateral hip pain following total hip arthroplasty. Patients were then stratified according to their change in femoral offset (<-5 mm, -5 mm < x < 5 mm, and 5 mm<). A chi squared analysis was then performed to see if there was a statistical difference in the rates of lateral hip pain amongst these groups.

RESULTS

A change in femoral offset of the implanted hip relative to the native hip was not associated with increased rates of lateral hip pain following total hip arthroplasty (p = 0.35). A change in femoral offset of the implanted hip relative to the contralateral hip was not associated with increased rates of lateral hip pain following total hip arthroplasty (p = 0.40).

CONCLUSION

This study found that there was no association between increased femoral offset and rates of postoperative lateral hip pain following total hip arthroplasty. Future investigations should look at a larger sample size with multiple institutions to further assess the impact on femoral offset changes on rates of persistent lateral hip pain.

A biomechanical study of the effect of weight loading conditions on the mechanical environment of the hip joint endoprosthesis

BACKGROUND

Total hip arthroplasty is one of the most successful orthopedic surgical procedures aiming to eliminate pain related to several types of hip arthritis and restore mobility. Obesity has been associated with an increased risk of complications after a total hip arthroplasty such as poor wound healing, periprosthetic joint infection, instability, and aseptic loosening.

METHODS

This paper presents an in-vitro study on composite femoral models to investigate the impact of different weight loading conditions on the mechanical environment of the hip joint endoprosthesis considering normal-weight and overweight individuals from 70 to 110 kg. The micro strains on the femur during single-leg stance of gait were measured on critical stress points based on the Gruen femoral zones.

FINDINGS

The micro strains increase as the weight increases implying that the displacement in the hip joint endoprosthesis is higher for overweight subjects enhancing the risk of failure. The highest increase was measured in Gruen zone 1 by 5.60% indicating that the great trochanter is subjected to higher stress shielding with increasing the weight. Also, the statistically significant increase of the micro strain values with increasing the weight in Gruen Zones 3 (2.91%), 5 (1.56%), and 11 (1.75%) may enhance the risk for a periprosthetic fracture at the lower region of the prosthesis.

INTERPRETATION

This is the first biomechanical study which quantifies the effect of increasing weight loading conditions on the mechanical environment of the hip joint endoprosthesis considering different positions of evaluation.

Does patient-reported perception of pain differ based on surgical approach in total hip arthroplasty?

Aims

Whether patient-reported pain differs among surgical approaches in total hip arthroplasty (THA) remains unclear. This study’s purposes were to determine differences in pain based on surgical approach (direct anterior (DA) vs posterolateral (PL)) and PL approach incision length.

Patients and Methods

This was a retrospective investigation from two centres and seven surgeons (three DA, three PL, one both) of primary THAs. PL patients were categorized for incision length (6 cm to 8 cm, 8 cm to 12 cm, 12 cm to 15 cm). All patients had cementless femoral and acetabular fixation, at least one year’s follow-up, and well-fixed components. Patients completed a pain-drawing questionnaire identifying the location and intensity of pain on an anatomical diagram. Power analysis indicated 800 patients in each cohort for adequate power to detect a 4% difference in pain (alpha = 0.05, beta = 0.80).

Results

A total of 1848 patients (982 DA, 866 PL) were included. PL patients were younger (59.4 years, sd 12.9 vs 62.7 years, sd 9.7; p < 0.001) and had shorter follow-up (3.3 years, sd 1.3 vs 3.7 years, sd 1.3; p < 0.001). DA patients reported decreased moderate to severe trochanteric (14% vs 21%; p < 0.001) and groin pain (19% vs 24%; p = 0.004) than PL patients. There were no differences in anterior, lateral, or posterior thigh, back, or buttock pain between cohorts (p = 0.05 to 0.7). PL approach incision length did not impact the incidence or severity of pain (p = 0.3 to 0.7).

Conclusion

A significant proportion of patients perceive persistent pain following THA regardless of approach. DA patients reported less trochanteric and groin pain versus PL patients. PL incision length did not influence the incidence or severity of patient-reported pain. Cite this article: Bone Joint J 2019;101-B(6 Supple B):31–36.