Treatment of Greater Trochanteric Bursitis in Patients with Total Hip Arthroplasty
For patients with greater trochanteric bursitis after total hip arthroplasty, a stepwise approach beginning with conservative measures including NSAIDs, physical therapy, and ultrasound-guided corticosteroid injections is recommended, with surgical intervention reserved for refractory cases. 1, 2
Diagnostic Approach
- Initial evaluation should include plain radiographs to rule out other causes of hip pain and assess the prosthesis 3
- For patients with trochanteric pain after radiographic evaluation, either ultrasound or MRI without IV contrast is appropriate for diagnosing trochanteric bursitis 3
- Ultrasound can effectively detect trochanteric bursitis but may be difficult to distinguish from gluteus medius tendinosis, as the two conditions often coexist 3, 1
- MRI can assess peritrochanteric structures including the gluteus minimus and medius muscles, abductor tendons, and the trochanteric bursa 3, 1
Treatment Algorithm
First-Line Treatment
- NSAIDs for pain relief and anti-inflammatory effects 1, 2
- Structured physical therapy focusing on stretching exercises for the iliotibial band and strengthening of hip abductor muscles 1, 2
- Activity modification to reduce pressure on the affected area 1
Second-Line Treatment
- Ultrasound-guided corticosteroid injection into the trochanteric bursa (provides both diagnostic confirmation and therapeutic benefit) 3, 1, 2
- Corticosteroid injections are effective in approximately 80% of cases, though up to 45% may require multiple injections 4
- Younger patients and those with leg-length discrepancy may be less responsive to conservative treatment 4
Refractory Cases
- Low-energy shock-wave therapy (SWT) has shown superior results compared to other non-operative modalities in comparative studies 5
- Surgical options for persistent trochanteric bursitis include:
Special Considerations for THA Patients
- Approximately 4.6% of patients develop trochanteric bursitis after primary total hip arthroplasty 4
- In patients with hip prostheses, extracapsular disease associated with adverse reactions to metal debris (ARMD) could be misinterpreted as trochanteric bursitis 3, 1
- Weakness or detachment of the abductor muscles may occur after THA using an anterolateral approach, which can contribute to trochanteric pain 3
- Distal lengthening of the iliotibial band by Z-plasty (Pedersen-Noor operation) has shown good results in patients with refractory trochanteric pain after THA 7
Clinical Pearls and Pitfalls
- Up to one-third of patients may fail initial therapy for trochanteric bursitis after THA 2
- Ensure proper diagnosis by differentiating trochanteric bursitis from other causes of lateral hip pain, including prosthesis-related issues 3
- Corticosteroid injections should be ultrasound-guided to ensure proper placement 1
- Consider leg-length discrepancy as a potential contributing factor in patients with persistent symptoms 4
- Surgical intervention should only be considered after failure of comprehensive conservative management 5, 6