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Arthroscopic bursectomy works for stubborn trochanteric bursitis

By Mary Ann Porucznik

Patients whose chronic recalcitrant trochanteric bursitis does not respond to nonsurgical interventions now have a choice. According to the presentation made by Champ L. Baker, MD, and R. Vaughan Massie, MD, arthroscopic bursectomy appears to be an effective and viable alternative to open bursectomy.

Trochanteric bursitis usually affects middle-aged patients, who are often unable to lie on the affected side and and who experience chronic pain that intensifies with adduction and internal rotation. The condition results from friction between the greater trochanter and the iliotibial band during active hip flexion and extension, resulting in microtrauma and mild degenerative changes of the gluteus medius and minimus tendons with associated bursal inflammation.

In their prospective study of 30 patients who did not respond to conservative treatment (physical therapy, nonsteroidal anti-inflammatory drugs, and corticosteroid injections), Drs. Baker and Massie found that arthroscopic bursectomy relieved pain and improved function. Patients’ improvements were usually evident by 1 to 3 months after surgery, and the improvements continued throughout the follow-up period.

A spinal needle is inserted for injection of saline. It is left in place for localization of the trochanteric prominence, and proximal and distal portals are established in line with the needle.

Two portals, local anesthetic
The surgery is performed using two portals—a proximal portal just posterior to the tip of the trochanter, and a distal portal just posterior to the inferior aspect of the bursa. A longitudinal incision, in line with the fibers of the iliotibial band, provides access to the bursa. “Trochanteric scuffing or irritation is often evident, and, occasionally seen in tears of the gluteal medius (often called a ‘rotator cuff tear’ of the hip),” reported Dr. Baker.

Outcome measurements
Outcomes were assessed using the Short Form-36 (SF-36), Harris Hip Score, a 0 (no pain) to 10 (worst pain) visual analog scale (VAS), and additional specific hip function questions. A paired-sample t-test was used to compare preoperative and postoperative scores.

A total of 25 patients were available for follow-up at an average of 26.1 months (range: 13.8 months to 41 months). Patients experienced improvements in both the physical and the mental component summary scores of the SF-36. Physical function scores increased from 33.6 (preoperative) to 54 (last follow-up). Mean pain category scores improved from 28.7 (preoperative) to 51.5 (postoperative).

Mean Harris Hip scores also improved from 51 (preoperative) to 77 (postoperative). VAS pain scale scores were cut in half—from the preoperative mean of 7.2 to a postoperative mean of 3.1. All changes were statistically significant.

An ablator is used to debride the bursa and its dense fibrous adhesions.

One patient with a postoperative complication—a seroma—required repeat surgery, and another patient subsequently underwent open bursectomy to resolve the symptoms.

“Arthroscopic bursectomy appears to be an effective, viable alternative to open bursectomy for patients who do not respond to conservative treatment,” said Dr. Baker. “Patients experienced good pain relief and improvements in overall function, and those improvements appear to be lasting.”

June 2007 AAOS Now
http://www.aaos.org/news/bulletin/jun07/clinical2.asp