Greater Trochanteric Bursa Removal During Total Hip Replacement
The greater trochanteric bursa is not routinely removed during total hip replacement, though some surgeons may excise it as part of their surgical approach—particularly when using a posterior approach or when the patient has pre-existing trochanteric bursitis. 1, 2
Surgical Practice Patterns
The decision to remove the trochanteric bursa during total hip arthroplasty varies by surgeon preference and surgical approach:
Most straightforward cases do not require trochanteric osteotomy or bursa excision, as modern surgical techniques allow adequate exposure without disturbing the greater trochanteric region 2
Trochanteric osteotomy (which would involve bursa removal) is reserved for complex cases including revision operations, severe deformities, limb shortening procedures, or when long stem components are needed 2
The posterior approach may involve more manipulation of the trochanteric region compared to the direct anterior approach, though neither approach routinely mandates bursa excision 3
Evidence on Prophylactic Bursectomy
A large retrospective cohort study directly addressed whether removing the bursa prevents post-operative trochanteric bursitis:
Prophylactic bursectomy does not reduce the incidence of post-operative trochanteric bursitis in patients undergoing primary total hip replacement 1
In a study of 954 patients, the overall incidence of post-THR trochanteric bursitis was only 0.5%, with no statistically significant difference between those who had bursectomy (4/554 patients) versus those who did not (1/400 patients) 1
However, synchronous bursectomy is effective for treating patients with known pre-existing trochanteric bursitis who require total hip replacement—7 of 8 such patients had resolution of their lateral buttock pain 1
Clinical Implications
Post-operative trochanteric pain occurs regardless of whether the bursa is removed:
The incidence of greater trochanteric pain after total hip replacement ranges from 4.6% to 29% depending on the surgical approach used 3, 4
The posterior approach is associated with higher rates of trochanteric pain (29%) compared to the direct anterior approach (17%), though this difference was not statistically significant 3
When post-operative trochanteric bursitis does occur, corticosteroid injection is effective in 80% of cases, with 45% requiring multiple injections 4
Important Caveats
Non-infected hip prostheses can show heterogeneous uptake in the greater trochanteric region on imaging, which should not be confused with infection 5
Radiographs showing greater than 2mm surface irregularities of the greater trochanter are associated with abductor tendon abnormalities, not necessarily bursitis 5, 6, 7
In patients with hip prostheses, extracapsular disease from adverse reactions to metal debris could be misinterpreted as trochanteric bursitis 6