Arthroscopic bursectomy with concomitant iliotibial band release for the treatment of recalcitrant trochanteric bursitis

Good functional outcomes after endoscopic treatment for greater trochanteric pain syndrome

PURPOSE

Greater trochanteric pain syndrome (GTPS) is a term covering different conditions generating lateral hip pain. Recalcitrant cases may require surgery but there are only a few studies evaluating endoscopic treatment. This study aimed to evaluate the outcome of endoscopically treated GTPS at minimum two years postoperatively using patient-reported outcome measures (PROMs), and to assess the complication rate associated with endoscopic surgery.

METHODS

A total of 33 patients, mean age 43.2 years, 88% women, with a mean symptom duration of 3.5 years, were included in the study. A total of 36 operated hips were included. Pre- and at minimum two years postoperatively the patients completed questionnaires consisting of the International Hip Outcome Tool (iHOT-12) and the Hip Sports Activity scale (HSAS), the Visual analogue scale for overall hip function (VAS-OHF), the Copenhagen Hip and Groin Outcome Score (HAGOS), the EuroQoL-5 Dimension Questionnaire (EQ-5D) and the EQ-VAS. Complications were assessed using the Clavien-Dindo classification.

RESULTS

Median follow-up time was 24.5 months postoperatively. Statistically significant improvements were seen for the following PROMs (p < 0.05); iHOT-12 (36.3 vs 54.0), HAGOS different subscores (40.8 vs 59.0, 46.5 vs 62.6, 29.9 vs 53.1, 33.5 vs 51.4, 20.7 vs 41.4, 23.4 vs 43.3), EQ-VAS (55.9 vs 63.3) and EQ-5D (0.392 vs 0.648). VAS-OHF and HSAS did not reach significance. There was a 71% satisfaction rate with the surgery. Three Clavien-Dindo grade 1 and one grade 2 complications were registered postoperatively, with 41% of patients achieving PASS for iHOT-12 at two years follow-up.

CONCLUSION

Endoscopic surgery for greater trochanteric pain syndrome improved patient-reported outcomes and the procedure was associated with low risk of complications.

LEVEL OF EVIDENCE

Level IV.

Endoscopic fascia lata release for treatment of gluteal tendinopathy: a prospective study with a follow-up of 6 months to 1 year

Greater trochanteric pain syndrome (GTPS) is clinically defined as greater trochanter pain with mechanical characteristics. The most common diagnosis is gluteal tendinopathy. Most cases of gluteal tendinopathy resolve with conservative management. In case of refractory pain endoscopic surgical treatment can resolved symptoms. This article presents a prospective study of endoscopic proximal fascia lata release associated to trochanteric bursectomy for recalcitrant trochanteric pain syndrome. 33 patients (35 hips) with refractory pain during more than six months were included. All patients were treated by endoscopic iliotibial band release and bursectomy according to Ilizaliturri. Outcomes were assessed by using Harris hip score and Womac hip score. Patients were follow-up until one year after surgery. The mean age was 53.7 years old, there was 9 men and 24 women. There were two bilateral cases in the female group. The average duration of conservative treatment was 20 months (CI95 9 to 31 months). 68% of patients were satisfied of the surgery with disappearance of pain after surgery. WOMAC and Harris hip score significantly improved after surgery until 6 months (respectively from 67 to 29 and from 40 to 76 - p<0.05). No complication was reported. Age, body mass index and duration of conservative treatment did not influence surgical results. This study showed that the endoscopic ilio tibial band (ITB) release and trochanteric bursectomy is simple, safe and easily reproductible but future prospective studies with a larger number of patients are required.

Snapping Hip Syndrome: A Comprehensive Update

Purpose of review

This is a comprehensive literature review regarding the pathogenesis, diagnosis, and treatment of snapping hip syndrome (SHS). It covers the diverse etiology of the syndrome and management steps from conservative to more advanced surgical techniques.

Recent Findings

Recent advances in imaging modalities may help in diagnosing and treating SHS. Additionally, arthroscopic procedures can prove beneficial in treating recalcitrant cases of SHS and have recently gained popularity due to their non-invasive nature.

Summary

SHS presents as an audible snap due to anatomical structures in the medial thigh compartment and hip. While often asymptomatic, in some instances, the snap is associated with pain. Its etiology can be broadly classified between external SHS and internal SHS, which involve different structures but share similar management strategies. The etiology can be differentiated by imaging and physical exam maneuvers. Treatment is recommended for symptomatic SHS and begins conservatively with physical therapy, rest, and anti-inflammatory medications. Most cases resolve after 6-12 months of conservative management. However, arthroscopic procedures or open surgical management may be indicated for those with persistent pain and symptoms. Different surgical approaches are recommended when treating internal SHS vs. external SHS. Due to advancements in treatment options, symptomatic SHS commonly becomes asymptomatic following intervention.

Ultrasound-guided surgery for lateral snapping hip: a novel ultraminimally invasive surgical technique

BACKGROUND

Greater trochanteric pain syndrome encompasses a range of causes of lateral hip pain including greater trochanteric bursitis, tendinopathy and tears of the gluteus minimus and medius, and lateral snapping hip (LSH). Surgical options for LSH range from open surgery to endoscopic surgery, including a diamond-shaped cut or a simple transversal release to gluteus maximus tendon release. Resection of an area of proximal iliotibial band (ITB) and step-cut or z-plasty lengthening have not proven superior to transverse release of the ITB. Therefore, making a complete and effective transverse cut guided by ultrasound may represent a potential advance over endoscopic surgery.

PURPOSE

In this case series study, we describe how to perform proximal release of the ITB guided by ultrasound.

METHODS

The surgical technique-either z-plasty or transverse section of the ITB-was first validated on 10 cadaver specimens and then used in clinical practice. Fourteen patients (5 males and 9 females) were operated from 2014 to 2018. Mean age was 43 years (29-62).

RESULTS

The snap resolved in all patients, as verified actively during the surgical procedure as the patient has only local anesthesia. The VAS score for sports activity improved from 7 (5-9) before surgery to 0 (0-2) after 1 year. The HSS score improved from 58 points (47-72) to 96 at 1-2 years. There were no complications other than minor hematomas nor recurrences.

CONCLUSION

Ultrasound-guided release of the LSH is a novel surgical option with encouraging results in patients for whom conservative protocols have failed. It can be performed under local anesthesia in an outpatient setting with minimal aggressiveness. It is relatively easy, quick, and painless; no stitches are required. Weight bearing is immediate, and patients usually need crutches for only 2-3 days. Although complete recovery may take 3 months, the rehabilitation protocol is fast and painless.

Radiofrequency Microdebridement as an Adjunct to Arthroscopic Surgical Treatment for Recalcitrant Gluteal Tendinopathy: A Double-Blind, Randomized Controlled Trial

Background:

Recalcitrant greater trochanteric pain is increasingly recognized as an indication for surgical intervention. The arthroscopic approach has become rapidly more common than the open alternative.

Hypothesis:

Patients undergoing radiofrequency microdebridement (RFMD) as an adjunct to arthroscopic gluteal bursectomy (AGB) and iliotibial band release (ITBR) will experience better functional improvement than AGB and ITBR alone at 1 year.

Study Design:

Randomized controlled trial; Level of evidence, 2.

Methods:

A total of 33 patients with failed nonoperative treatment of gluteal tendinopathy were randomly allocated to undergo AGB/ITBR or AGB/ITBR + RFMD. Full-thickness tears were excluded. The primary outcome measure was the modified Harris Hip Score (mHHS) at 52 weeks. Secondary outcome measures included the mHHS, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), visual analog scale (VAS) for pain, and 12-item Short Form Health Survey (SF-12), which were evaluated at 0, 6, 12, 24, and 52 weeks. Statistical significance was defined as P < .05.

Results:

A total of 33 participants (33 hips; 30 female and 3 male; mean age, 58 years) were randomized; 16 patients underwent AGB/ITBR + RFMD, and 17 underwent AGB/ITBR. Participants’ functionality improved in both groups at all time intervals. The mean mHHS score improved from 57.49 ± 10.61 to 77.76 ± 18.40 (P = .004) and from 58.98 ± 12.33 to 79.96 ± 18.86 (P = .001) at 52 weeks in the AGB/ITBR and AGB/ITBR + RFMD groups, respectively, although there was no statistically significant difference between groups. There were no device-related adverse events.

Conclusion:

AGB/ITBR led to significant improvements in patients with recalcitrant gluteal tendinopathy. In this small RCT, the addition of RFMD showed no additional benefit to AGB/ITBR but provided a safe adjunct for the surgical management of recalcitrant gluteal tendinopathy.

Registration:

NCT01562366 (ClinicalTrials.gov identifier).

Long-term outcome of low-energy extracorporeal shockwave therapy on gluteal tendinopathy documented by magnetic resonance imaging

Background

Previous outcome studies for extracorporeal shock wave therapy (ESWT) have included clinically diagnosed greater trochanteric pain syndrome (GTPS). The purpose of this study is to investigate outcome of ESWT on GTPS with gluteal tendinopathy documented by magnetic resonance imaging (MRI).

Methods

Medical records of 38 consecutive patients were retrospectively reviewed, who underwent ESWT for GTPS with MRI-documented gluteal tendinopathy (> 6 months). ESWT was conducted (1/week) when the Roles-Maudsley score (RMS) showed “Poor” or “Fair” grade after conservative treatment until RMS had reached “Good” or “Excellent” grade (treatment success) or until 12 treatments had been applied. Numeric rating scale (NRS) and RMS were evaluated before, 1 week after (immediate follow-up) and mean 27 months after ESWT program (long-term follow-up). Success rate was calculated at each follow-up point.

Results

Initial NRS (5.9 ± 1.6) significantly decreased at immediate (2.5 ± 1.5, p< 0.01) and long-term follow-up (3.3 ± 3.0, p< 0.01), respectively. Success rates were 83.3% (immediate) and 55.6% (long-term), respectively. There was no correlation among age, symptom duration and NRS.

Conclusion

Low-energy ESWT can be an effective treatment for pain relief in chronic GTPS with MRI-documented gluteal tendinopathy. However, its long-term effect appears to decrease with time.

Outcomes of Arthroscopic Management of Trochanteric Bursitis in Patients With Femoroacetabular Impingement: A Comparison of Two Matched Patient Groups

PURPOSE

To determine the prevalence of chronic trochanteric bursitis (TB) in patient being treated for femoroacetabular impingement (FAI) and determine the effectiveness of arthroscopic bursectomy and iliotibial band lengthening (AB-ITB-L) at the time of hip arthroscopy for FAI.

METHODS

Patients diagnosed with primary FAI and chronic TB were included in the study. Patients were included if they underwent hip arthroscopy with labral repair, femoral and/or acetabular osteoplasty, and AB-ITB-L. Patients were matched by age and gender to patients without chronic TB.

RESULTS

The prevalence of chronic TB with FAI was 7% (90/1,278). Females were 5.3 times more likely to have TB compared with males (95% confidence interval: 3.2-8.7). Patients more than 30 years of age were 2.5 times more likely to have TB (95% confidence interval: 1.48-4.4). Of the 90 patients diagnosed with TB, 72 (54 female, 18 male) with an average age of 36.7 years underwent AB-ITB-L at the time of their index hip arthroscopy for FAI. All 72 patients had associated intra-articular pathology consisting of a combined cam and pincer pathology. The TB (average follow-up = 42 ± 9.9 months) and non-TB group (average follow-up = 42 ± 9.1 months) both had significant improvement from preoperative to postoperative scores for Hip Outcome Score Activities Daily Living, Hip Outcome Score Sport, Modified Harris Hip Score, Western Ontario and McMaster Universities Arthritis Index, Short Form (SF)-12 Physical Component score, and SF-12 Mental Component Score. There was no significant difference between the 2 groups in postoperative patient reported outcome scores.

CONCLUSIONS

The occurrence of chronic TB in the FAI population, which did not adequately respond to nonoperative management, for a single surgeon high volume hip arthroscopy practice was 7%, and was more commonly seen in women older than 30 years. Patients who undergo concomitant AB-ITB-L for chronic TB report excellent pain relief, and have equivalent results and outcome scores that are not inferior when compared with patients with primary FAI without chronic TB.

LEVEL OF EVIDENCE

Level III, retrospective matched case control study.

High prevalence of greater trochanteric pain syndrome among patients presenting to spine clinic for evaluation of degenerative lumbar pathologies

BACKGROUND

Greater trochanteric pain syndrome (GTPS) is a relatively common diagnosis among the general population.

OBJECTIVE

We aim to determine the prevalence of GTPS among patients who presented to the spine clinic.

METHODS

Medical records of patients who were evaluated in the spine clinic were reviewed over a 12-month period (4/1/2016 to 3/31/2017). Patient demographics, presenting symptomatology, physical examination findings, presence or absence of GTPS, medical imaging findings, and interventions were recorded analyzed. Statistical analysis was performed using SPSS Statistics 23.0 (Chicago, IL). Statistical significance is defined as p < 0.05.

RESULTS

A total of 273 consecutive patients (145 women, 128 men) were evaluated for degenerative lumbar pathologies by a single spine surgeon over the study period. The average patient age was 61.9 years. Overall, there were 138/273 patients (50.5%) with GTPS (Group I), while 135/273 patients (49.5%) did not have GTPS (Group II). There were 73 patients in Group I received trochanteric injection for GTPS treatment and subsequently returned to clinic for follow-up, and there were 36/73 (49.3%) patients reporting improvement in their symptoms after trochanteric injection. There was a statistically significant predilection for presence of GTPS in the female gender (60% vs 32.8%, p = <0.01). There was no statistically significant difference in the prevalence of low back pain, buttock, thigh or groin pain between the two groups.

CONCLUSION

GTPS is a very common but often unrecognized or misdiagnosed condition. Accurate diagnosis and differentiation of GTPS from lumbar spinal pathologies are essential in avoiding potential unnecessary spinal procedures.

The outcome of endoscopy for recalcitrant greater trochanteric pain syndrome

INTRODUCTION

Greater trochanteric pain syndrome (GTPS), previously referred as trochanteric bursitis, is a debilitating condition characterised by chronic lateral hip pain. The syndrome is thought to relate to gluteal tendinopathy, with most cases responding to non-operative treatment. A number of open and endoscopic surgical techniques targeting the iliotibial band, trochanteric bursa and gluteal tendons have, however, been described for severe recalcitrant cases. We report the outcomes of one such endoscopic approach here.

MATERIALS AND METHODS

We retrospectively reviewed 49 patients (57 operations) who had undergone endoscopic longitudinal vertical iliotibial band release and trochanteric bursectomy. Inclusion criteria included diagnosed GTPS with a minimum of six months of non-operative treatment. Exclusion criteria included concomitant intra- or extra-articular hip pathology and previous hip surgery including total hip arthroplasty. Outcomes were assessed using the Visual Analogue Scale, Oxford hip Score and International Hip Outcome Tool (iHOT-33).

RESULTS

The series included 42 females and 7 males with a mean age of 65.0 years (26.7-88.6). Mean follow-up time was 20.7 months (5.3-41.2). Eight patients had full thickness gluteal tendon tears, of which 7 were repaired. Adjuvant PRP was injected intraoperatively in 38 of 57 operations (67.2 %). At follow-up, overall mean Visual Analogue Scale values had decreased from 7.8 to 2.8 (p < 0.001), Oxford hip Scores had increased from 20.4 to 37.3 (p < 0.001) and iHOT-33 scores had increased from 23.8 to 70.2 (p < 0.001). Of the 57 operations performed, patients reported feeling very satisfied with the surgical outcome in 28 operations (49.1 %), satisfied in 17 operations (29.8 %) and less than satisfied in 12 operations (21.1 %).

CONCLUSIONS

While the majority of patients with GTPS will improve with non-operative management, endoscopic iliotibial band release, trochanteric bursectomy and gluteal tendon repair is a safe and effective treatment for severe recalcitrant cases.

Percutaneous Fascia Release for Treating Chronic Recurrent Gluteal Myofascial Pain—A Pilot Study of a New Technique

Objective

To investigate the therapeutic effectiveness of percutaneous fascia release to treat chronic recurrent gluteal myofascial pain related to recurrent tendonitis or bursitis at the attachment sites.

Methods

Five patients (three males, two females; aged 48.6 ± 8.9 years) with myofascial trigger points in the gluteus medius muscle were treated. Outcome measures, including pain intensity, pressure pain threshold, and the relative strength of hip abduction, were assessed before, immediately after, and six months after the treatment. The data measured before and after treatment (different times) on visual analog scale, pressure pain threshold, and relative hip abduction strength were analyzed by Wilcoxon signed-rank test and paired t-test, respectively, for the comparisons between time points.

Results

Reduction in pain intensity and increase in the pressure pain threshold and the relative hip abduction strength were found in all five patients after treatment when compared with those of before treatment ( P < 0.05). Moreover, all of these improvements existed for at least six months ( P > 0.05).

Conclusions

Percutaneous fascia release of gluteal muscle insertion sites can be used to treat chronic gluteal pain related to subtrochanteric bursitis to avoid recurrence, if other treatment cannot control the recurrence, although this was demonstrated only on a small sample size without control and blind assessment in the pilot study.

Gluteal Tendinopathy: Integrating Pathomechanics and Clinical Features in Its Management

Synopsis Gluteal tendinopathy is now believed to be the primary local source of lateral hip pain, or greater trochanteric pain syndrome, previously referred to as trochanteric bursitis. This condition is prevalent, particularly among postmenopausal women, and has a considerable negative influence on quality of life. Improved prognosis and outcomes in the future for those with gluteal tendinopathy will be underpinned by advances in diagnostic testing, a clearer understanding of risk factors and comorbidities, and evidence-based management programs. High-quality studies that meet these requirements are still lacking. This clinical commentary provides direction to assist the clinician with assessment and management of the patient with gluteal tendinopathy, based on currently limited available evidence on this condition and the wider tendon literature and on the combined clinical experience of the authors. J Orthop Sports Phys Ther 2015;45(11):910-922. Epub 17 Sep 2015. doi:10.2519/jospt.2015.5829.

Femoroacetabular impingement: current concepts in diagnosis and treatment

As a result of reading this article, physicians should be able to: 1. Identify the etiology of femoroacetabular impingement. 2. Assess femoroacetabular impingement on physical examination. 3. Recognize femoroacetabular impingement on imaging studies. 4. Discuss modern techniques to effectively treat femoroacetabular impingement, both open and arthroscopic. Femoroacetabular impingement (FAI) is a recently proposed concept describing abnormal anatomic relationships within the hip joint that may lead to articular damage. Impingement is caused by bony deformities or spatial malorientation of the femoral head-neck junction and/or the acetabulum. These abnormalities lead to pathologic contact and shearing forces at the acetabular labrum and cartilage during physiological hip motion. There is an increasing body of evidence that these forces lead to cartilage wear and eventual osteoarthritis. Treatment options for FAI are evolving rapidly. Although the gold standard remains open hip dislocation, arthroscopic techniques have shown significant promise. It is possible that early recognition and treatment of subtle deformity about the hip may reduce the rate of hip osteoarthritis in the future.

Gluteal tendon repair augmented with a synthetic ligament: surgical technique and a case series

We describe an augmented surgical repair technique for gluteus minimus and medius tears, along with a supportive case series. A consecutive series of 22 patients presenting with clinical and radiological findings consistent with hip abductor tears, who had undergone failed prior conservative treatments, were prospectively recruited. Patients underwent open bursectomy, Y-iliotibial release, debridement of the diseased tendon, decortication of the trochanteric foot-plate and reattachment augmented with a LARS ligament through a trans-osseous tunnel, together with suture anchors. All patients were assessed pre- and postoperatively to 12 months with the Oxford Hip Score (OHS), the Short-Form Health Survey (SF-36) and a Visual Analogue Pain Scale (VAS), while a satisfaction scale was employed at 12 months. A statistically significant improvement (p<0.05) was observed for all patient reported outcome measures, while all patients were at least 'satisfied' with the procedure at 12 months. One patient reported some lateral hip discomfort at 10 months, and removal of the LARS interference screw provided immediate relief. One patient had a urological catheter-related complication. With no other complications and no clinical failures of the repair, we believe the technique to be safe and reliable, whilst reducing the incidence of re-tears as reported in the existing literature.

Trochanteric bursitis: the last great misnomer

Trochanteric bursitis has been used as a general term to describe pain around the greater trochanteric region of the hip. We hypothesised that trochanteric bursitis may not however have an inflammatory component and that accordingly, bursal inflammation has no role in lateral hip pain. This study was designed to test this hypothesis. Patients undergoing primary total hip replacement were enrolled in this prospective, case-controlled, blinded study. Twenty-five patients who met the criteria for diagnosis of trochanteric bursitis (group A) were matched with a control group of 25 patients (group B). Trochanteric bursal samples were harvested from all patients intraoperatively and sent for histological analysis for the presence of inflammation. The intraoperative appearance of the abductor tendon insertion was also noted. None of the samples showed any evidence of acute or chronic inflammatory changes. Intraoperatively, five patients (20%) in group A were noted to have thinning of the gluteus medius tendon but no macroscopic tendon tears were detected in any bursal samples. This study suggests that there is no inflammatory component to so-called trochanteric bursitis, which accordingly casts doubt on both the terminology and the existence of this condition as a separate clinical entity. Clinicians should search for an alternative cause of symptoms in such cases.

Practical approach to hip pain

Hip pain is a common complaint among patients presenting to outpatient clinics. Stratifying patients based on age, acuity, and location of pain (extra-articular vs intra-articular) can help to aid in appropriate imaging and timely referral to an orthopedic surgeon. A thorough history and an organized physical examination combined with radiographs are usually sufficient to diagnose most hip complaints. If the diagnosis remains uncertain, magnetic resonance imaging, usually with intra-articular gadolinium, is the imaging modality of choice in diagnosing both intra-articular and extra-articular pathologies.

Current possibilities for hip arthroplasty

Hip arthroscopy has been popularized over the last decade and, with technical advances regarding imaging diagnostics, understanding of the physiopathology or surgical techniques, several applications have been described. Both arthroscopy for intra-articular conditions and endoscopy for extra-articular procedures can be used in diagnosing or treating different conditions. This updated article has the objective of presenting the various current possibilities for hip arthroscopy.

The running athlete: stress fractures, osteitis pubis, and snapping hips

CONTEXT

Pelvic stress fractures, osteitis pubis, and snapping hip syndrome account for a portion of the overuse injuries that can occur in the running athlete.

EVIDENCE ACQUISITION

PUBMED SEARCHES WERE PERFORMED FOR EACH ENTITY USING THE FOLLOWING KEYWORDS: snapping hip syndrome, coxa sultans, pelvic stress fracture, and osteitis pubis from 2008 to 2013. Topic reviews, case reports, case series, and randomized trials were included for review.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Collectively, 188 articles were identified. Of these, 58 were included in this review.

CONCLUSION

Based on the available evidence, the majority of these overuse injuries can be managed non-operatively. Primary treatment should include removal from offending activity, normalizing regional muscle strength/length imbalances and nutritional deficiencies, and mitigating training errors through proper education of the athlete and training staff.

STRENGTH OF RECOMMENDATION TAXONOMY

C.

A review of femoroacetabular impingement and hip arthroscopy in the athlete

Femoroacetabular impingement (FAI) is increasingly recognized as a pathological condition of the hip in athletes. Although it is not always symptomatic, the bone structure leading to FAI and its associated pathology can result in significant pain and performance decline in athletes. Recognition of athletes with symptomatic FAI is of the utmost importance, as prompt treatment is necessary in order to maintain desired sports activity levels and preserve joint function. This review explores the recent evidence on the evaluation, recognition, and treatment of femoroacetabular impingement, and discusses conservative management, postoperative rehabilitation, and treatment in the pediatric and master athlete populations.

Greater trochanteric pain syndrome: does imaging-identified pathology influence the outcome of interventions?

AIM

To assess the outcomes for patients seen in a rheumatology service presenting with features of the greater trochanteric pain syndrome (GTPS) and the impact of imaging results on the outcomes of treatment.

METHODS

Retrospective audit, using a phone interview was performed to establish links between results of imaging undertaken in the diagnostic work-up of patients with lateral hip pain and clinical outcomes for these patients. Patient perceptions of the effectiveness of interventions were also assessed.

RESULTS

Forty-five patients were included (82% female, mean age 69.6 years). Sixty-nine percent underwent radiological work-up, including plain X-rays (55%), computed tomography scans (64%), magnetic resonance imaging (48%) and ultrasound (90%). Coexistent trochanteric bursitis (TB) and gluteal tendinopathy were the most commonly elucidated pathologies accounting for the symptomatic presentation of 40% of patients. Forty-one patients underwent some form of intervention, most commonly injection of local anesthetic and corticosteroid (LACS) into the region of the TB (87%), two-thirds of which were undertaken under radiological guidance. Pain reduction was maximal following the third injection, with a significantly better response to unguided interventions and levels of symptomatic relief following the first injection being a good indicator of the probability of complete remission. Radiological demonstration of isolated TB correlated with a greater reduction in lateral hip symptoms following LACS TB injections both in the immediate post-injection phase and in the long-term.

CONCLUSION

The results of this audit suggest that the management of GTPS has reasonable patient outcomes; however, a prospective study with greater patient numbers is needed to confirm these results.

Ultrasonography-assisted arthroscopic proximal iliotibial band release and trochanteric bursectomy

We describe arthroscopic iliotibial band release and trochanteric bursectomy assisted by intraoperative ultrasonography for accurate placement of arthroscopic portals and to ensure adequate decompression of the peritrochanteric space. We have found ultrasonography for endoscopic iliotibial band release a useful tool to assist with localizing the site and length of decompression.

Management of labral tears of the hip in young patients

Our understanding of labral tears in young patients has evolved significantly in recent years. Successful outcome depends on addressing all bony impingement to improve the intra-articular environment, and prevent further damage to the labrum and articular cartilage. Improved clinical outcomes are associated with labral repair; in cases of a deficient labrum, arthroscopic reconstruction techniques have been developed, with promising clinical outcomes. This article reviews the anatomy of the acetabular labrum, and discusses the pathogenesis of labral tears as well as various treatment options, including arthroscopic labral repair and reconstruction.

Hip arthroscopy for extra-articular hip disease

The increasing popularity and success of hip arthroscopy has led to the development of related techniques for treating hip pathologies external to the joint proper. These minimally invasive endoscopic procedures serve in a diagnostic role to complement clinical evaluations and offer a therapeutic alternative to traditional open techniques. The indications for extra-articular hip endoscopy continue to expand. Recent literature describes applications for treating greater trochanteric pain syndrome, internal snapping hip, deep gluteal syndrome, and subspine impingement and for diagnosing and treating extra-articular sources of hip pain in patients who have undergone hip arthroplasty.

Peri-articular diseases of the hip: emerging frontiers in arthroscopic and endoscopic treatments

The precise diagnosis of both intra and extra-capsular disease of the hip is now possible because of commonly available advanced diagnostic imaging techniques. An increasing number of reports in the orthopedic literature describe new endoscopic and arthroscopic techniques to address peri-articular pathology of the hip. The purpose of this paper is to review current techniques in the management of extra-articular hip conditions.

Extra-articular hip endoscopy: A review of the literature

The aim of this review is to evaluate the current available literature evidencing on peri-articular hip endoscopy (the third compartment). A comprehensive approach has been set on reports dealing with endoscopic surgery for recalcitrant trochanteric bursitis, snapping hip (or coxa-saltans; external and internal), gluteus medius and minimus tears and endoscopy (or arthroscopy) after total hip arthroplasty. This information can be used to trigger further research, innovation and education in extra-articular hip endoscopy.

Accessibility of extra-articular pathologies of iliopsoas tendon and bursitis of greater trochanter in hip arthroscopy

PURPOSE

Different pathologies leading to psoas tendon pain and chronic bursitis of the greater trochanter are well known. The purpose of the study was to underline the accessibility of the psoas tendon at lesser trochanter, reproduce the results and measure the distances to anatomical landmarks.

METHODS

Twelve hips of six human cadavers underwent hip arthroscopy. The accessibility of the iliopsoas tendon at the lesser trochanter and the bursa at the greater trochanter was documented with the camera. In addition to the usual access portals, alternative ventral ports were analysed concerning accessibility of the lesser trochanter. Afterwards, arthroscopy needles were placed along the extra-articular portals followed by dissection. The distances of the portals in relation to important anatomical landmarks were analysed.

RESULTS

The accessibility to the iliopsoas tendon at the lesser trochanter and to the bursa at the greater trochanter throughout the conventional portals was reproducible. Sufficient distances to the important anatomical landmarks could be shown. The mean distance of the distal ventro-lateral and the wide distal ventro-lateral portal to the nervous cutaneous femoris lateralis was 26.8 ± 5.4 mm and 32.2 ± 3.9 mm. The mean distance from the more ventral located portals to the nervous arteria and vena femoralis was 28.3 ± 2.1 mm.

CONCLUSION

This is the first study known to us that describes in detail the accessibility of the extra-articular structures underlined by anatomical preparation. In addition, it was demonstrated that a more ventrally located portal had sufficient distance to the important neurovascular structures of the ventral femur and can also be used in addendum if necessary.

Posterior hip pain in an athletic population: differential diagnosis and treatment options

Context:

Posterior hip pain is a relatively uncommon but increasingly recognized complaint in the orthopaedic community. Patient complaints and presentations are often vague or nonspecific, making diagnosis and subsequent treatment decisions difficult. The purposes of this article are to review the anatomy and pathophysiology related to posterior hip pain in the athletic patient population.

Evidence Acquisition:

Data were collected through a thorough review of the literature via a MEDLINE search of all relevant articles between 1980 and 2010.

Results:

Many patients who complain of posterior hip pain actually have pain referred from another part of the body—notably, the lumbar spine or sacroiliac joint. Treatment options for posterior hip pain are typically nonoperative; however, surgery is warranted in some cases.

Conclusions:

Recent advancements in the understanding of hip anatomy, pathophysiology, and treatment options have enabled physicians to better diagnosis athletic hip injuries and select patients for appropriate treatment.

Lateral hip pain in an athletic population: differential diagnosis and treatment options

CONTEXT

Historically, the term greater trochanteric pain syndrome has been used to describe a spectrum of conditions that cause lateral-sided hip pain, including greater trochanteric bursitis, snapping iliotibial band, and/or strains or tendinopathy of the abductor mechanism. Diagnosis of these conditions may be difficult because clinical presentations are variable and sometimes inconclusive. Especially difficult is differentiating intrinsic pain from pain referred to the greater trochanteric region. The purposes of this article are to review the relevant anatomy and pathophysiology of the lateral hip.

EVIDENCE ACQUISITION

Data were collected through a thorough review of the literature conducted through a MEDLINE search of all relevant papers between 1980 and January 2010.

RESULTS

Recent advances in imaging and an improved understanding of pathomechanics have helped to guide the evaluation, diagnosis, and appropriate treatment for patients presenting with lateral hip pain.

CONCLUSION

Various diagnostic tools and treatment modalities can be used to effectively manage the athletic patient presenting with lateral hip pain.

Endoscopic bursectomy and iliotibial tract release as a treatment for refractory greater trochanteric pain syndrome: a new endoscopic approach with early results

Greater trochanteric pain syndrome (GTPS) is associated with excessive tension between the iliotibial band (ITB) and the greater trochanter. Several endoscopic procedures have been reported, but in most cases the endoscopic approach only consists of a bursectomy. The ITB and fascia lata act as a lateral tension band to resist tensile strains on the concave aspect of the femur and are often implicated as the source of GTPS. We therefore believe that the ITB must be addressed. We describe an endoscopic technique to release the ITB and remove the bursa and conclude that endoscopic bursectomy with cross incision of the ITB is a safe approach to treat patients with refractory GTPS.

Soft tissue pathology around the hip

Snapping hip syndromes have been treated with open surgery for many years. Recently, endoscopic techniques have been developed for treatment of snapping hip syndromes with results that are at least comparable if not better than those reported for open procedures. The greater trochanteric pain syndrome is well known by orthopedic surgeons. However, deep understanding of the pathologic conditions generating pain in the greater trochanteric region and endoscopic access to it has only recently been described. Although evidence regarding endoscopic techniques for the treatment of the greater trochanteric pain syndrome is mainly anecdotal, early published reports are encouraging.

Partial-thickness tears of the gluteus medius: rationale and technique for trans-tendinous endoscopic repair

Tears in the gluteus medius and minimus tendons, often misdiagnosed as trochanteric bursitis, have recently emerged as an important cause of recalcitrant greater trochanter pain syndrome. Advances in endoscopic surgery of the hip have created opportunities to better evaluate and treat pathology in the peritrochanteric compartment. We reviewed the literature on trochanteric pain syndrome and gluteus medius tendon injuries. Existing techniques for endoscopic and open gluteus tendon repair and potential challenges in restoration of abductor function were analyzed. Partial-thickness undersurface tears of the gluteus medius were identified as a common pathologic entity. Although these tears are otherwise analogous to partial-thickness tears of the rotator cuff, the lack of arthroscopic access to the deep side of the gluteus medius tendon represents a unique technical challenge. To address the difficulty in visualizing and thus repairing undersurface tears of the gluteus medius, a novel endoscopic trans-tendinous repair technique was developed. The purposes of this article are to review the anatomy, pathology, and existing repair techniques of gluteus medius tendon tears and to describe the rationale and surgical steps for endoscopic trans-tendinous repair.

Greater trochanteric pain syndrome

Originally defined as "tenderness to palpation over the greater trochanter with the patient in the side-lying position," greater trochanteric pain syndrome (GTPS) as a clinical entity, has expanded to include a number of disorders of the lateral, peritrochanteric space of the hip, including trochanteric bursitis, tears of the gluteus medius and minimus and external coxa saltans (snapping hip). Typically presenting with pain and reproducible tenderness in the region of the greater trochanter, buttock, or lateral thigh, GTPS is relatively common, reported to affect between 10% and 25% of the general population. Secondary to the relative paucity of information available on the diagnosis and management of components of GTPS, the presence of these pathologic entities may be underrecognized, leading to extensive workups and delays in appropriate treatment. This article aims to review the present understanding of the lesions that comprise GTPS, discussing the relevant anatomy, diagnostic workup and recommended treatment for trochanteric bursitis, gluteus medius and minimus tears, and external coxa saltans.

Does ultrasound correlate with surgical or histologic findings in greater trochanteric pain syndrome? A pilot study

BACKGROUND

Greater trochanteric pain syndrome can be severely debilitating. Ideal imaging modalities are not established, treatments are not reliably evaluated, and the underlying pathology is not well understood.

QUESTIONS/PURPOSES

Using surgical and histopathology findings as a gold standard, we therefore determined the positive predictive value of preoperative ultrasound assessment for greater trochanteric pain syndrome recalcitrant to nonoperative management. In addition, we report the outcomes of gluteal tendon reconstructive surgery using validated clinical and functional outcome tools and evaluate the contribution of the tendon and bursa to greater trochanteric pain syndrome.

PATIENTS AND METHODS

We reviewed 24 patients who had combined gluteal tendon reconstruction and bursectomy. Preoperative ultrasound imaging was compared with surgical findings. In the absence of a greater trochanteric pain syndrome specific outcome tool, surgical outcomes for pain and function were assessed via a 100-mm visual analog scale, the modified Harris hip score, and the Oswestry Disability Index. Strength also was measured. The tendon and bursa tissue collected at surgery was histopathologically reviewed.

RESULTS

In our small study, ultrasound had a high positive predictive value for gluteal tendon tears (positive predictive value = 1.0). Patients reported high levels of pain relief and function after surgery; tendon and bursa showed pathologic changes.

CONCLUSIONS

Ultrasound appears to be clinically useful in greater trochanteric pain syndrome; reconstructive surgery seems to relieve pain and the histopathologic findings show tendinopathy and bursa pathology coexist in greater trochanteric pain syndrome.

LEVEL OF EVIDENCE

Level IV, case series. See the Guidelines for Authors for a complete description of levels of evidence.

Balloon dissection for improved access to the peritrochanteric compartment

Nonarthritic, trochanteric pain is a commonly encountered orthopaedic condition. Although most patients respond to conservative treatment, those with recalcitrant symptoms may require surgical intervention. Studies have successfully explored the use of the arthroscope in the treatment of these patients. We report a new technique for an arthroscopic approach to the peritrochanteric space. Our technique involves the use of a balloon trocar for fast and improved dissection and visualization of the peritrochanteric compartment in hip arthroscopy.

Home training, local corticosteroid injection, or radial shock wave therapy for greater trochanter pain syndrome

BACKGROUND

There are no controlled studies testing the efficacy of various nonoperative strategies for treatment of greater trochanter pain syndrome. Hypothesis The null hypothesis was that local corticosteroid injection, home training, and repetitive low-energy shock wave therapy produce equivalent outcomes 4 months from baseline.

STUDY DESIGN

Randomized controlled clinical trial; Level of evidence, 2.

METHODS

Two hundred twenty-nine patients with refractory unilateral greater trochanter pain syndrome were assigned sequentially to a home training program, a single local corticosteroid injection (25 mg prednisolone), or a repetitive low-energy radial shock wave treatment. Subjects underwent outcome assessments at baseline and at 1, 4, and 15 months. Primary outcome measures were degree of recovery, measured on a 6-point Likert scale (subjects with rating completely recovered or much improved were rated as treatment success), and severity of pain over the past week (0-10 points) at 4-month follow-up.

RESULTS

One month from baseline, results after corticosteroid injection (success rate, 75%; pain rating, 2.2 points) were significantly better than those after home training (7%; 5.9 points) or shock wave therapy (13%; 5.6 points). Regarding treatment success at 4 months, radial shock wave therapy led to significantly better results (68%; 3.1 points) than did home training (41%; 5.2 points) and corticosteroid injection (51%; 4.5 points). The null hypothesis was rejected. Fifteen months from baseline, radial shock wave therapy (74%; 2.4 points) and home training (80%; 2.7 points) were significantly more successful than was corticosteroid injection (48%; 5.3 points).

CONCLUSION

The role of corticosteroid injection for greater trochanter pain syndrome needs to be reconsidered. Subjects should be properly informed about the advantages and disadvantages of the treatment options, including the economic burden. The significant short-term superiority of a single corticosteroid injection over home training and shock wave therapy declined after 1 month. Both corticosteroid injection and home training were significantly less successful than was shock wave therapy at 4-month follow-up. Corticosteroid injection was significantly less successful than was home training or shock wave therapy at 15-month follow-up.

Low-energy extracorporeal shock wave therapy as a treatment for greater trochanteric pain syndrome

BACKGROUND

Greater trochanteric pain syndrome is often a manifestation of underlying gluteal tendinopathy. Extracorporeal shock wave therapy is effective in numerous types of tendinopathies.

HYPOTHESIS

Shock wave therapy is an effective treatment for chronic greater trochanteric pain syndrome.

STUDY DESIGN

Case control study; Level of evidence, 3.

METHODS

Thirty-three patients with chronic greater trochanteric pain syndrome received low-energy shock wave therapy (2000 shocks; 4 bars of pressure, equal to 0.18 mJ/mm(2); total energy flux density, 360 mJ/mm(2)). Thirty-three patients with chronic greater trochanteric pain syndrome were not treated with shock wave therapy but received additional forms of nonoperative therapy (control). All shock wave therapy procedures were performed without anesthesia. Evaluation was by change in visual analog score, Harris hip score, and Roles and Maudsley score.

RESULTS

Mean pretreatment visual analog scores for the control and shock wave therapy groups were 8.5 and 8.5, respectively. One, 3, and 12 months after treatment, the mean visual analog score for the control and shock wave therapy groups were 7.6 and 5.1 (P < .001), 7 and 3.7 (P < .001), and 6.3 and 2.7 (P < .001), respectively. One, 3, and 12 months after treatment, mean Harris hip scores for the control and shock wave therapy groups were 54.4 and 69.8 (P < .001), 56.9 and 74.8 (P < .001), and 57.6 and 79.9 (P < .001), respectively. At final follow-up, the number of excellent, good, fair, and poor results for the shock wave therapy and control groups were 10 and 0 (P < .001), 16 and 12 (P < .001), 4 and 13 (P < .001), and 3 and 8 (P < .001), respectively. Chi-square analysis showed the percentage of patients with excellent (1) or good (2) Roles and Maudsley scores (ie, successful results) 12 months after treatment was statistically greater in the shock wave therapy than in the control group (P < .001).

CONCLUSION

Shock wave therapy is an effective treatment for greater trochanteric pain syndrome.

Distal fascia lata lengthening: an alternative surgical technique for recalcitrant trochanteric bursitis

This article presents a simple technique for fascia lata lengthening that is less aggressive, can be performed under local anaesthetic with little morbidity and disability, and has excellent results. Eleven patients (13 hips) were enrolled in this study. Mean age was 54.6 years, there was one man and ten women. Outcomes were assessed by using a visual analog pain scale, Harris hip score and Lickert scale (satisfaction). There was a mean follow-up time of 43 months (range 15-84). All patients were scored by the Harris hip scale with a mean improvement from 61 (range 48-77) to 91 (range 76-95) after surgery. The mean visual analogue scale (VAS) score improved from 83 (range 60-99) to 13 (range 0-70). We had 12 of 13 patients reporting a good result. Mean surgical time was 15 min, and only one seroma was reported as a complication. No inpatient management was needed. In conclusion, distal "Z" lengthening of the fascia lata appears to be a good alternative for treatment of this condition.

Differential diagnosis of pain around the hip joint

The differential diagnosis of hip pain is broad and includes intra-articular pathology, extra-articular pathology, and mimickers, including the joints of the pelvic ring. With the current advancements in hip arthroscopy, more patients are being evaluated for hip pain. In recent years, our understanding of the functional anatomy around the hip has improved. In addition, because of advancements in magnetic resonance imaging, the diagnosis of soft tissue causes of hip pain has improved. All of these advances have broadened the differential diagnosis of pain around the hip joint and improved the treatment of these problems. In this review, we discuss the causes of intra-articular hip pain that can be addressed arthroscopically: labral tears, loose bodies, femoroacetabular impingement, capsular laxity, tears of the ligamentum teres, and chondral damage. Extra-articular diagnoses that can be managed arthroscopically are also discussed, including: iliopsoas tendonitis, "internal" snapping hip, "external" snapping hip, iliotibial band and greater trochanteric bursitis, and gluteal tendon injury. Finally, we discuss extra-articular causes of hip pain that are often managed nonoperatively or in an open fashion: femoral neck stress fracture, adductor strain, piriformis syndrome, sacroiliac joint pain, athletic pubalgia, "sports hernia," "Gilmore's groin," and osteitis pubis.

Correlation of MRI findings with clinical findings of trochanteric pain syndrome

OBJECTIVE

Greater trochanter pain syndrome due to tendinopathy or bursitis is a common cause of hip pain. The previously reported magnetic resonance (MR) findings of trochanteric tendinopathy and bursitis are peritrochanteric fluid and abductor tendon abnormality. We have often noted peritrochanteric high T2 signal in patients without trochanteric symptoms. The purpose of this study was to determine whether the MR findings of peritrochanteric fluid or hip abductor tendon pathology correlate with trochanteric pain.

MATERIALS AND METHODS

We retrospectively reviewed 131 consecutive MR examinations of the pelvis (256 hips) for T2 peritrochanteric signal and abductor tendon abnormalities without knowledge of the clinical symptoms. Any T2 peritrochanteric abnormality was characterized by size as tiny, small, medium, or large; by morphology as feathery, crescentic, or round; and by location as bursal or intratendinous. The clinical symptoms of hip pain and trochanteric pain were compared to the MR findings on coronal, sagittal, and axial T2 sequences using chi-square or Fisher's exact test with significance assigned as p < 0.05.

RESULTS

Clinical symptoms of trochanteric pain syndrome were present in only 16 of the 256 hips. All 16 hips with trochanteric pain and 212 (88%) of 240 without trochanteric pain had peritrochanteric abnormalities (p = 0.15). Eighty-eight percent of hips with trochanteric symptoms had gluteus tendinopathy while 50% of those without symptoms had such findings (p = 0.004). Other than tendinopathy, there was no statistically significant difference between hips with or without trochanteric symptoms and the presence of peritrochanteric T2 abnormality, its size or shape, and the presence of gluteus medius or minimus partial thickness tears.

CONCLUSIONS

Patients with trochanteric pain syndrome always have peritrochanteric T2 abnormalities and are significantly more likely to have abductor tendinopathy on magnetic resonance imaging (MRI). However, although the absence of peritrochanteric T2 MR abnormalities makes trochanteric pain syndrome unlikely, detection of these abnormalities on MRI is a poor predictor of trochanteric pain syndrome as these findings are present in a high percentage of patients without trochanteric pain.