Basic Anatomy of the Peritrochanteric Space of the Hip

The most superficial layer of the peritrochanteric space consists of the fibromuscular sheath of the gluteus maximus, tensor fascia lata, and iliotibial band (ITB). The greater trochanter is considered the deep boundary of this anatomic region, which contains the following structures: trochanteric bursa, tendinous insertions of the gluteal muscles, and the origin vastus lateralis. Table 1 summarizes the anatomy and function of the gluteal muscles. The trochanteric bursa is superficial to the hip abductor muscles and deep to the ITB.

Endoscopic Evaluation of the Peritrochanteric Space

With the rapid expansion of minimally invasive surgical techniques in orthopedics, most of the peritrochanteric space disorders can be addressed endoscopically. ^, Lall and colleagues described a classification system that is useful in the diagnosis and management of greater trochanteric space pain syndrome (GTPS; type I-V) primarily based on endoscopic findings ( Table 2 ), and by taking into account the physical examination and imaging diagnosis.

Trochanteric Bursitis

Inflammation of the trochanteric bursa is commonly diagnosed in middle aged or older individuals, and stems from the repetitive friction of the bursa between the greater trochanter and ITB during hip motion. Patients with this condition present with lateral hip or buttock pain and peritrochanteric tenderness is characteristic on physical examination. Although some patients present with isolated trochanteric bursitis, this condition might be associated with intra-articular hip joint pathology (femoroacetabular impingement, arthritis) or gluteal tendinopathy or tear. ^, Because of this, imaging testing of the hip joint with radiograph and possibly MRI must be considered to reveal the diagnosis. The initial, nonoperative management of trochanteric bursitis may include rest, activity modification, physical therapy, oral medication (nonsteroidal anti-inflammatory), or local injection therapy (corticosteroids, local anesthetic, platelet-rich plasma). ^{, ,}

Surgical management consists of the excision of the inflamed trochanteric bursa, and it is the preferred treatment in cases of failure of conservative measures. Excellent clinical outcomes have been reported in patients undergoing trochanteric bursectomy (isolated or in combination with arthroscopic femoroacetabular impingement (FAI) surgery or gluteal tendon repair) using previously described open or endoscopic surgical techniques. ^{, ,} The endoscopic approach offers the advantages of smaller skin incision and reduced normal tissue violation, which might accelerate the postoperative recovery of the patient.

Snapping Hip Syndrome

Patients with coxa saltans or snapping hip syndrome often describe a “click” that is heard or felt during movement of the hip joint, and is sometimes accompanied by hip pain. This condition is common among dancers and is categorized into three types, based on the cause. ^, External snapping hip is caused by sliding of the ITB over the greater trochanter, whereas internal snapping hip is most commonly the result of iliopsoas tendon sliding over the femoral head, prominent iliopectineal ridge, lesser trochanter, or the iliopsoas bursa. Intra-articular snapping hip syndrome is associated with the presence of loose bodies in the hip joint or labral tears. ^,

In patients with external snapping syndrome, applying pressure over the greater trochanter with the patient’s hip in flexion often stops snapping. ^, Reproduction of internal hip snapping during physical examination is achieved by passive movement of the hip from flexion and external rotation to extension and internal rotation. Radiographic evaluation may include an anteroposterior hip radiograph (which is normal in most patients), but MRI is useful in cases where additional intra-articular hip or peritrochanteric pathology are suspected.

Physical therapy with or without local injection therapy is the first-line therapy for snapping hip syndrome, regardless of type. Patients with external snapping hip syndrome who fail to improve with conservative measures may undergo surgical excision of the trochanteric bursa in combination with Z plasty of ITB. In cases of internal snapping hip syndrome that is resistant to nonoperative therapy, iliopsoas tendon release might be performed. Psoas tenotomy can also be performed in patients with internal snapping hip following total hip replacement with satisfactory outcomes. In patients with intra-articular snapping hip syndrome, treatment must focus on the correction of the existing the intra-articular hip pathology, which might result in the resolution of snapping without additional intervention.

Gluteal Tendinopathy

Diagnosis

Careful history and physical examination must be completed when evaluating patients with lateral-sided hip pain and suspected gluteal tendinopathy or tear. Patients commonly report insidious onset of lateral hip pain associated with weight bearing, lying on affected hip, and/or difficulty with ascending or descending stairs. Gluteal tendinopathy occurs four times more often in women than men and is most prevalent between the ages of 50 and 80. ^, Patients will have often attempted and failed nonoperative treatments of trochanteric bursitis. Physical examination findings including tenderness to palpation of the greater trochanter, decreased abduction strength, and abductor atrophy may be notable. Patients may also walk with an antalgic and/or Trendelenburg gait. ^,

The most commonly used imaging includes plain radiographs, ultrasonography, and MRI. ^, Patients with gluteal tendinopathy and abductor tears often have unremarkable plain films, although radiographs are important at ruling out other differentials including degenerative joint disease, femoroacetabular impingement, and dysplasia. ^, Walsh and colleagues evaluated the plain radiographs of 72 patients with surgically treated abductor tendon tears. Patients with long-standing symptoms were more likely to have spurs in superior and inferior facet with a normal-appearing lateral margin of the trochanter, and new boney growth over anterior facet.

MRI is the most sensitive and specific study to confirm a gluteal tendinopathy and rule out other intra-articular and extra-articular disorders ( Fig. 1 ). Similar to rotator cuff injuries of the shoulder, tears can range from partial thickness to full thickness. Increased signal intensity of the gluteal tendon on T2-weighted images is consistent with a partial tear. Full-tendon tears show discontinuity of the tendon, with or without atrophy. The Goutallier-Fuchs classification is frequently used to classify fatty infiltration of the gluteal muscles (0 = normal muscle; 1 = some fatty streaks; 2 = moderate fatty streaks, although more muscle than fat; 3 = severe fatty muscle with equal amounts muscle and fat; and 4 = muscle contains more fat than muscle).

MRI study of the right hip (coronal view) showing tear of the gluteus minimums and gluteus medius tendons with subgluteus bursal fluid collection.

More recently in the literature, there has been increasing evidence that amount of fatty muscle atrophy is correlated with decreased postoperative outcomes. ^, Thaunat and colleagues evaluated the short-term outcomes of patients with endoscopically repaired partial- and full-thickness tears of gluteus medius. Preoperative MRIs were graded using the gluteus medius fatty degeneration index and found to be strongly negatively correlated with postoperative modified Harris hip score (mHHS), nonarthritic hip score, and visual analog scale for pain (VAS pain) and patient-rated overall satisfaction.

Management of gluteal tendinopathy or tear

Initial treatment should start with a trial of nonoperative treatments including nonsteroidal anti-inflammatory drugs, physical therapy, activity modification, and corticosteroid injections. Nonoperative management often fails and patients endorse persistent pain and abduction weakness on physical examination. Surgical indications have been suggested for patients who failed to improve with conservative treatment, exhibit 6 months of symptoms, MRI-confirming gluteal tendon tear, pain relief with injection, and/or the evolving fatty degeneration of the gluteus medius or minimus muscle. Increased time to intervention could have negative effects on outcomes in patients with retracted tendons or fatty degeneration.

Surgical interventions include open versus endoscopic gluteal tendon repair ( Table 3 ). Both have been reported to improve patient pain, limp, and abduction strength. Advantages of the arthroscopic approach ( Fig. 2 ) include assessing or treating concomitant periarticular pathology. Open procedures have easier visualization of the pathology. Such factors as size of the tear, retraction of the tendon, amount of fatty degeneration, atrophy of the muscle, and bone mineral density may affect the outcome of surgery. Maslaris and colleagues found that patients with larger tears and fatty degeneration were more likely to be treated open. Ebert and colleagues completed an extensive literature review of surgically treated gluteus tendon surgical repair method and patient outcomes and concluded that there is sufficient evidence to recommend gluteal tendon repairs treated either open or endoscopically.

Table 3

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