Introduction

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

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

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

History

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

Physical examination

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

Imaging and diagnostic studies

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

Indications

Operative intervention is indicated for the following patients:

Surgical technique

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

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

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

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