The role of arthroscopic bursectomy in the treatment of trochanteric bursitis

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.

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.

Three Sessions of Radial Extracorporeal Shockwave Therapy Gives No Additional Benefit Over "Minimal-Dose" Radial Extracorporeal Shockwave Therapy for Patients With Chronic Greater Trochanteric Pain Syndrome: A Double-Blinded, Randomized, Controlled Trial

OBJECTIVE

To investigate the outcomes following 3 weekly sessions of radial extracorporeal shockwave therapy (rESWT) in patients with chronic greater trochanteric pain syndrome (GTPS) presenting to an NHS Sports Medicine Clinic in the United Kingdom.

DESIGN

Double-blinded randomized controlled trial.

SETTING

A single NHS Sports Medicine Clinic, in the United Kingdom.

PATIENTS

One hundred twenty patients in an NHS Sports Medicine clinic presenting with symptoms of GTPS who had failed to improve with a minimum of 3 months of rehabilitation were enrolled in the study and randomized equally to the intervention and treatment groups. Mean age was 60.6 ± 11.5 years; 82% were female, and the mean duration of symptoms was 45.4 ± 33.4 months (range, 6 months to 30 years).

INTERVENTIONS

Participants were randomized to receive either 3 sessions of ESWT at either the "recommended"/"maximally comfortably tolerated" dose or at "minimal dose." All patients received a structured home exercise program involving flexibility, strength, and balance exercises.

MAIN OUTCOME MEASURES

Follow-up was at 6 weeks, 3 months, and 6 months. Outcome measures included local hip pain, validated hip PROMs (Oxford hip score, non-arthritic hip score, Victorian Institute of Sport assessment questionnaire), and wider measures of function including sleep (Pittsburgh sleep quality index) and mood (hospital anxiety and depression scale).

RESULTS

Results were available for 98% of patients at the 6-month period. There were statistically significant within-group improvements in pain, local function, and sleep seen in both groups. However, fewer benefits were seen in other outcome measures, including activity or mood.

CONCLUSION

There were no time × group interaction effects seen between the groups at any time point, indicating that in the 3 sessions, the "recommended-dose" rESWT had no measurable benefit compared with "minimal dose" rESWT in this group of patients with GTPS. The underlying reason remains unclear; it may be that rESWT is ineffective in the treatment of patients with chronic GTPS, that "minimal dose" rESWT is sufficient for a therapeutic effect, or that a greater number of treatment sessions are required for maximal benefit. These issues need to be considered in further research.

Identifying the Most Successful Procedures in Hip Arthroscopy

Hip arthroscopy for femoral and acetabular pathologies has increased dramatically. However, there is little literature analyzing procedures as predictors of revision arthroscopy or arthroplasty. From February 2008 to November 2015, patients undergoing hip arthroscopy for a labral tear with minimum 2-year follow-up and between 18 and 60 years old were retrospectively reviewed. Those with previous surgeries, Tönnis grade greater than 1, and previous hip conditions were excluded. Follow-up was obtained for 1118 patients (1249 hips; 81.7%) with a mean age of 38.7 years (range, 18.0-60.0 years), mean body mass index of 26.4 kg/m² (range, 16.3-48.9 kg/m²), and mean follow-up of 50.2 months (range, 24.0-111.9 months). A total of 122 (9.8%) patients converted to total hip arthroplasty (mean, 35.3 months; range, 1.4-95.2 months). Multivariate analysis for predictors of total hip arthroplasty found age at surgery (hazard ratio, 1.064/y; P<.05), body mass index (nonlinear; P<.05), labral debridement (HR, 1.558; P=.03), and notchplasty (HR, 2.128; P<.05), with trochanteric bursectomy (HR, 0.367; P<.05) identified as associated with higher survivorship. A total of 124 (9.9%) patients underwent revision hip arthroscopy at a mean of 21.7 months (range, 0.10-83.3 months). Multivariate analysis for predictors of revision surgery found workers' compensation (HR, 3.352; P<.05), capsular repair (HR, 1.950; P<.05), and femoral head microfracture (HR, 2.844; P=.04) to be significant, with age at date of surgery (HR, 0.973/y; P<.05) and femoral head chondroplasty (HR, 0.241; P=.05) associated with higher survivorship. Understanding risk factors for conversion to total hip arthroplasty or revision is paramount during discussions with patients. [Orthopedics. 2020;43(3):173-181.].

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).

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.

Tendon Disorders After Total Hip Arthroplasty: Evaluation and Management

BACKGROUND

Most patients who undergo total hip arthroplasty are very satisfied with their outcomes. However, there is a small subset of patients who have persistent pain after surgery. The etiology of pain after total hip arthroplasty varies widely; however, tendon disorders are a major cause of debilitating pain that often go unrecognized.

METHODS

We performed a literature review to identify the most common tendon pathologies after total hip arthroplasty which include iliopsoas tendinitis, greater trochanteric pain syndrome, snapping hip syndrome, and abductor tendinopathy.

RESULTS

We present a simplified approach highlighting the presentation and management of patients with suspected tendinopathies after total hip arthroplasty. These tendinopathies are treatable, and management begins with nonoperative modalities; however, in cases not responsive to conservative management, operative intervention may be necessary.

CONCLUSION

Tendinopathies after total hip arthroplasty sometimes go unrecognized but when treated can result in higher surgeon and patient satisfaction.

Endoscopic Trochanteric Bursectomy and Iliotibial Band Release for Persistent Trochanteric Bursitis

Lateral hip pain associated with trochanteric bursitis is a common orthopedic condition, and can be debilitating in chronic or recalcitrant situations. Conservative management is the most common initial treatment and often results in resolution of symptoms and improved patient outcomes. These modalities include rest, activity modification, physical therapy, anti-inflammatory medication, or corticosteroid injections. However, there is a subset of patients in which symptoms persist despite exhaustive conservative modalities. For these patients, trochanteric bursectomy is a surgical option to address persistent pathology. Previous literature indicates that both open and arthroscopic surgical techniques can be used to address the inflamed bursa and results in good patient outcomes. However, recent advances in hip arthroscopy have allowed for improvements in minimally invasive techniques to address intracapsular and extracapsular pathology of the hip, including recalcitrant trochanteric bursitis. The purpose of this manuscript is to describe our technique for a minimally invasive arthroscopic trochanteric bursectomy.

Disorders of the Peritrochanteric and Deep Gluteal Space: New Frontiers for Arthroscopy

Arthroscopic techniques for the hip joint have evolved into endoscopic methods for extra-articular disorders. These endoscopic strategies provide a less invasive alternative to open procedures for traditionally recognized forms of pathology. Endoscopy has defined new disorders amenable to surgical correction and has redefined some of these existing disorders. The peritrochanteric and deep gluteal regions represent 2 of the most currently active areas of exploration. Peritrochanteric problems include trochanteric bursitis, full-thickness and partial-thickness tears of the abductors including the gluteus medius and minimus, and external coxa saltans (snapping iliotibial band). Deep gluteal disorders include piriformis syndrome, and other variations of deep gluteal syndrome, and ischiofemoral impingement. Each of these evolving areas is highlighted in this chapter.

Greater Trochanteric Pain Syndrome

Patients who have lateral hip pain historically have been diagnosed with trochanteric bursitis and treated with nonsteroidal anti-inflammatory medications, corticosteroid injections, and physical therapy. Although this strategy is effective for most patients, a substantial number of patients continue to have pain and functional limitations. Over the past decade, our understanding of disorders occurring in the peritrochanteric space has increased dramatically. Greater trochanteric pain syndrome encompasses trochanteric bursitis, external coxa saltans (ie, snapping hip), and abductor tendinopathy. A thorough understanding of the anatomy, examination findings, and imaging characteristics aids the clinician in treating these patients. Open and endoscopic treatment options are available for use when nonsurgical treatment is unsuccessful.

Rehabilitation Following Hip Arthroscopy - A Systematic Review

Context

Rehabilitation following hip arthroscopy is an integral component of the clinical outcome of the procedure. Given the increase in quantity, complexity, and diversity of procedures performed, a need exists to define the role of rehabilitation following hip arthroscopy.

Objectives

(1) To determine the current rehabilitation protocols utilized following hip arthroscopy in the current literature, (2) to determine if clinical outcomes are significantly different based on different post-operative rehabilitation protocols, and (3) to propose the best-available evidence-based rehabilitation program following hip arthroscopy.

Data sources

Per PRISMA guidelines and checklist, Medline, SciVerse Scopus, SportDiscus, and Cochrane Central Register of Controlled Trials were searched.

Study selection

Level I–IV evidence clinical studies with minimum 2-year follow-up reporting outcomes of hip arthroscopy with post-operative rehabilitation protocols described were included.

Data extraction

All study, subject, and surgery parameters were collected. All elements of rehabilitation were extracted and analyzed. Descriptive statistics were calculated. Study methodological quality was analyzed using the modified Coleman methodology score.

Results

Eighteen studies were included (2,092 subjects; 52% male, mean age 35.1 ± 10.6 years, mean follow-up 3.2 ± 1.0 years). Labral tear and femoroacetabular impingement were the most common diagnoses treated and labral debridement and femoral/acetabular osteochondroplasty the most common surgical techniques performed. Rehabilitation protocol parameters (weight-bearing, motion, strengthening, and return to sport) were poorly reported. Differences in clinical outcomes were unable to be assessed given heterogeneity in study reporting. Time-, phase-, goal-, and precaution-based guidelines were extracted and reported.

Conclusion

The current literature of hip arthroscopy rehabilitation lacks high-quality evidence to support a specific protocol. Heterogeneity in study, subject, and surgical demographics precluded assimilation of protocols and/or outcomes to generate evidence-based guidelines. Strengths and limitations in the literature were identified. Future studies should recognize and report the essentials of rehabilitation following hip arthroscopy.

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.

Endoscopic repair of partial-thickness undersurface tears of the gluteus medius tendon

Partial-thickness tear of the gluteus medius and minimus muscles has recently been recognized as a cause of chronic trochanteric pain resistant to medical treatment. The present article reports an original endoscopic technique of identification and repair. It uses a standard arthroscope at 30°, with the patient in lateral decubitus, without fluoroscopy. In case of partial-thickness undersurface tear, careful hook palpation followed by bursa exploration enables the pathological tendon to be diagnosed. A trans-tendinous approach then allows debridement, with systematic resection of the bone structures implicated in the impingement, followed by side-to-side tendon suture.

LEVEL OF EVIDENCE

Level IV (case series).

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.

Trochanteric area pain, the result of a quartet of bursal inflammation

Bursitis is quite responsive to therapeutic intervention, once the afflicted area is accurately identified. This is especially notable for some hip complaints. Patients’ use of the term “hip” can relate to anything from the low back to groin to lateral thigh pain. Trochanteric area surface localization of “hip” pain may afford an opportunity for immediate cure. Effectiveness of therapeutic intervention is predicated upon injection of not one or two, but all four peri-trochanteric bursa with a depot (minimally water-soluble) corticosteroid. The term trochanteric bursitis suggests that the inflammation is more focal than what is clinically observed. While easier to express, perhaps it is time to refer to inflammation in this area, naming all four affected bursae.

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.

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.

Surgical repair of the gluteal tendons: a report of 72 cases

Lateral hip pain is a common problem in middle-aged women. This pain is usually attributed to trochanteric bursitis and treated as such. This study reports the results of investigation, the findings at surgery, the operative technique, the histopathologic findings, and the results of gluteal tendon repair in 72 patients with long-standing trochanteric pain and reports a classification of the operative findings. Six patients (7%) in the original study cohort of 89 patients were lost to follow-up, but of the remaining patients, 65 of 72, or 90%, were pain-free or had minimal pain (P < .00001). Surgical reconstruction of detached gluteal tendons causing chronic lateral hip pain addresses the problem directly and reliably relieves the symptoms of so-called "trochanteric bursitis."

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.

The evidence for hip arthroscopy: grading the current indications

PURPOSE

The purpose of this systematic review is to provide a comprehensive analysis of the Level of Evidence and the Grade of Recommendation for hip arthroscopy.

METHODS

A literature review was performed (in June 2010) using the PubMed and Cochrane databases. Studies that focused on the efficacy of hip arthroscopy for all therapeutic indications were reviewed to determine their Level of Evidence. The studies were grouped based on indication, and the literature supporting each indication was analyzed and assigned a Grade of Recommendation. A subscale proposed by us was used to further describe the evidence base for indications receiving a Grade of Recommendation indicating poor-quality evidence.

RESULTS

Fair evidence (grade B) exists to support the surgical technique of hip arthroscopy for the treatment of femoroacetabular impingement. Poor-quality evidence (grade C(f)) exists to support a recommendation for the use of hip arthroscopy in the treatment of acetabular labral tears, extra-articular lesions, septic arthritis, and loose bodies. There is poor-quality conflicting evidence (C(c)) regarding the use of hip arthroscopy for the treatment of mild to moderate osteoarthritis of the hip.

CONCLUSIONS

Although fair evidence (grade B) exists to support the use of hip arthroscopy for the treatment of femoroacetabular impingement, a majority of recognized indications for this surgical technique currently lack adequate evidence-based support in the literature (grade C or grade I). Higher-quality trials (Level I and Level II) are needed to provide support for the increasing application of this surgical technique. We also applied a new subscale to the grades of recommendation for summaries or reviews of orthopaedic surgical studies proposed by Wright et al. to provide a description of the direction in which outcomes are trending in Level IV studies.

LEVEL OF EVIDENCE

Level IV, systematic review.

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.

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.

The safe zone for hip arthroscopy: a cadaveric assessment of central, peripheral, and lateral compartment portal placement

PURPOSE

This study evaluated 11 arthroscopic portals (4 central, 4 peripheral, and 3 peritrochanteric) with regard to their proximity to neurovascular structures and the extra-articular path taken before entering their intended compartments.

METHODS

We established 11 standard portals in 10 cadaveric hips, under arthroscopic and fluoroscopic visualization, using 3/16-inch Steinmann pins. Each hip was dissected, and the relation of the pins to the pertinent anatomy was recorded to the nearest 1 mm.

RESULTS

Only 2 of the 11 portals, the anterior and midanterior portals, came within 2 cm of a neurovascular structure before entering their respective compartments. The anterior portal placed the lateral femoral cutaneous nerve at risk, lying at a mean of 15.4 mm (range, 1 to 28 mm) away. The midanterior portal lies a mean of 19.2 mm (range, 5 to 42 mm) from the ascending branch of the lateral circumflex femoral artery. In addition, a small terminal branch of this artery courses a mean of 14.7 mm (range, 2 to 33 mm) and 10.1 mm (range, 1 to 23 mm) from the anterior portal and midanterior portal, respectively.

CONCLUSIONS

This study showed that 11 arthroscopic portals can be safely inserted into the central, peripheral, and peritrochanteric compartments of the hip. The midanterior and anterior portals pass in close proximity to a small terminal branch of the ascending lateral circumflex femoral artery. The greatest risk still comes from the proximity of the anterior portal to the lateral femoral cutaneous nerve. However, a slightly more lateral location seems to provide substantial benefits.

CLINICAL RELEVANCE

This study investigated 11 arthroscopic hip portals inserted in a standardized fashion. This knowledge should help surgeons place the necessary portals both safely and accurately.

Arthroscopic anatomy and surgical techniques for peritrochanteric space disorders in the hip

Disorders of the lateral or peritrochanteric space (often grouped into the greater trochanteric pain syndrome), such as recalcitrant trochanteric bursitis, external snapping iliotibial band, and gluteus medius and minimus tears, are now being treated endoscopically. We outline the endoscopic anatomy of the peritrochanteric space of the hip and describe surgical techniques for the treatment of these entities. Proper portal placement is key in understanding the peritrochanteric space and should be first oriented at the gluteus maximus insertion into the linea aspera, as well as the vastus lateralis. When tears of the gluteus medius and minimus are encountered, suture anchors can be placed into the footprint of the abductor tendons in a standard arthroscopic fashion. Our initial experience indicates that recalcitrant trochanteric bursitis, external coxa saltans, and focal, isolated tears of the gluteus medius and minimus tendon may be successfully treated with arthroscopic bursectomy, iliotibial band release, and decompression of the peritrochanteric space and suture anchor tendon repair to the greater trochanter, respectively.

Arthroscopic bursectomy for recalcitrant trochanteric bursitis

PURPOSE

The purpose of this prospective study was to evaluate the arthroscopic treatment of trochanteric bursitis in patients who have not responded to nonoperative treatment.

METHODS

Thirty patients were enrolled in this study to evaluate the results of arthroscopic bursectomy. Outcomes were assessed by use of a visual analog pain scale, Harris Hip Score, Short Form 36 Health Survey, and additional specific hip function questions. Patients were given the self-administered outcome questionnaires before surgery and at subsequent follow-up visits. Of the patients, 25 were available for a mean follow-up of 26.1 months (range, 13.8 to 41 months).

RESULTS

Pain scores on the visual analog scale improved from a preoperative mean of 7.2 (0, no pain; 10, worst pain) to a postoperative mean of 3.1 at final follow-up (P = .0001). Mean Harris Hip Scores improved from a mean of 51 preoperatively to 77 at follow-up (P = .0001). Improvements were also noted in the physical component summary scores of the Short Form 36. The mean physical function score improved from 33.6 preoperatively to 54 at follow-up (P = .022), and in the pain category, the mean score improved from 28.7 to 51.5 (P = .001). One postoperative complication occurred, a seroma that required repeat surgery. One patient had a failed arthroscopic bursectomy and subsequently underwent open bursectomy with resolution of symptoms.

CONCLUSIONS

Arthroscopic bursectomy appears to be an effective option for recalcitrant trochanteric bursitis and is a viable alternative to open bursectomy. In this prospective study patients had good pain relief and improved function compared with their preoperative status. Improvements in a patient's status are usually evident by 1 to 3 months after surgery and appear to be lasting.

LEVEL OF EVIDENCE

Level IV, therapeutic case series.

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

Trochanteric bursitis with lateral hip pain is a commonly encountered orthopaedic condition. Although most patients respond to corticosteroid injections, rest, physical therapy (PT), stretching, and anti-inflammatory medications, those with recalcitrant symptoms may require operative intervention. Studies have explored the use of the arthroscope in the treatment of these patients. However, these reports have not addressed the underlying pathology in this chronic condition. We believe that the iliotibial band must be addressed and is the main cause of pain, inflammation, and trochanteric impingement leading to the development of bursitis. We report a new technique for arthroscopic trochanteric bursectomy with iliotibial band release. Our technique involves 2 incisions--one 4 cm proximal to the greater trochanter along the anterior border of the iliotibial band, and the other 4 cm distal and along the posterior border. The 30 degrees arthroscope is introduced through the inferior portal, and a cannula is introduced through the superior portal. A 5.5-mm arthroscopic shaver is inserted through the superior cannula to clear off the surface of the iliotibial band, so that it may be adequately visualized. A hooked electrocautery probe is then used to longitudinally incise the iliotibial band until it no longer rubs, causing impingement over the greater trochanter.

Arthroscopic surgery of the hip: current concepts and recent advances

This review describes the development of arthroscopy of the hip over the past 15 years with reference to patient assessment and selection, the technique, the conditions for which it is likely to prove useful, the contraindications and complications related to the procedure and, finally, to discuss possible developments in the future.

Z-lengthening of the iliotibial band to treat recalcitrant cases of trochanteric bursitis

Greater trochanteric bursitis is a relatively common presentation at hip clinics. It presents with pain around the greater trochanter. Diagnosis is usually made on clinical grounds when other hip and spinal pathologies are ruled out and there is tenderness present over the trochanteric region. Rheumatoid arthritis (1), athletic injury (2), total hip arthroplasty (3) and idiopathic disease (4) are some of the known causes of trochanteric bursitis. Treatment is mainly non-operative and expectant; however various operative interventions have been described in the literature. We present a series of 16 patients who had recalcitrant trochanteric bursitis following failed non-operative treatment and were treated with bursectomy and Z-lengthening of the iliotibial band. All 14 patients who answered the questionnaire were happy with the outcome of operation and 13/14 patients would undergo a similar procedure again. To the best of our knowledge, this is the only series in the literature describing this particular procedure for treatment of trochanteric bursitis.

Early results of endoscopic trochanter bursectomy

Between 1995 and 2000, we performed 45 endoscopic bursectomies in 42 patients (average age 51, range 17-61 years). All patients had at least 6 months of failed conservative treatment, and all responded positively to a sonographic-guided injection with Mepivacaine 0.5%. The bursa was removed using a synovial resector. An additional tractopexie was performed in four cases. We followed 37 patients for 12-48 months. Pre-operatively, the mean modified Japanese Orthopaedic Association (JOA) disability hip score was 40.5 points. It improved to 72.6 points after a mean of 25 months. Severe complications did not occur. The minimally invasive technique requires only stab incisions, and immobilisation and hospitalisation are minimal.

MR imaging of sports-related hip disorders

Hip arthroscopy is being used increasingly for the diagnosis and treatment of hip disorders. MR imaging performed with appropriate technical considerations may aid not only in preoperative planning but in the appropriate selection of patients, which tends to lead to better postoperative results. Although the painful hip is imaged most commonly by radiography, MR imaging is considered the next imaging test of choice for evaluation of most common hip abnormalities in athletes, including labral injuries, ligament injuries, osteochondral injuries, fractures, bursitis, and musculotendinous injuries. MR arthrography can be a particularly useful technique for dedicated assessment of hip joint internal derangements.