Trochanteric Bursitis After Total Hip Arthroplasty

Transcription

1 The Journal of Arthroplasty Vol. 25 No Trochanteric Bursitis After Total Hip Arthroplasty Incidence and Evaluation of Response to Treatment Kevin W. Farmer, MD, Lynne C. Jones, PhD, Kirstyn E. Brownson, BA, Harpal S. Khanuja, MD, and Marc W. Hungerford, MD Abstract: We examined the efficacy of corticosteroid injection as treatment for postarthroplasty trochanteric bursitis and the risk factors for failure of nonoperative treatment. There were 32 (4.6%) cases of postsurgical trochanteric bursitis in 689 primary total hip arthroplasties. Of the 25 hips with follow-up, 11 (45%) required multiple injections. Symptoms resolved in 20 (80%) but persisted in 5. We found no statistically significant differences between patients who did and did not develop trochanteric bursitis, or between those who did and did not respond to treatment. There was a trend toward younger age and greater limb-length discrepancy in nonresponders. In conclusion, (1) corticosteroid injection(s) for postoperative trochanteric bursitis is effective; and (2) nonoperative management may be more likely to fail in young patients and those with leg-length discrepancy. Keywords: trochanteric bursitis, lateral trochanteric pain, total hip arthroplasty, corticosteroid injection Elsevier Inc. All rights reserved. Trochanteric bursitis, or lateral trochanteric pain, is a known complication of total hip arthroplasty, with reported rates ranging from 4% to 17% [1-4]. Iorio et al [1] recently reported 5-year postoperative incidences of lateral trochanteric pain after total hip arthroplasty of 5.0% with the direct lateral approach and 1.2% with the posterior approach. This entity can be distinguished from intraarticular or implant pathology by the lateral location of pain worsened with palpation, the lack of groin pain, and the absence of start-up pain. Shbeeb and Metteson [5] postulated that trochanteric bursitis likely is secondary to repetitive microtrauma and that alterations in the biomechanics of the lower extremity and changes in hip muscle mechanics may predispose patients to this condition. Scar tissue formation and changes in hip joint mechanics after total hip arthroplasty may explain some of the cases of trochanteric bursitis after total hip arthroplasty. When considering the diagnosis of trochanteric bursitis, other possibilities should be entertained including gluteus medius/minimus tendinopathies, L2/L3 From the Division of Arthritis Surgery, The Department of Orthopaedic Surgery, The Johns Hopkins University at Good Samaritan Hospital, Baltimore, Maryland. Submitted September 10, 2008; accepted February 4, No benefits or funds were received in support of the study. Reprint requests: Marc W. Hungerford, MD, 4940 Eastern Ave., #A672, Baltimore, MD Elsevier Inc. All rights reserved /09/ $36.00/0 doi: /j.arth radiculopathy, lumbar arthritides with referred pain, and entrapment neuropathies [1]. Corticosteroids have long been used in the treatment of atraumatic trochanteric bursitis [6-9]. In the study by Iorio et al [1], all cases of trochanteric bursitis after total hip arthroplasty resolved with a combination of nonoperative treatments. To date, there have been no other studies examining the response to treatment of patients with this complication. The purposes of this study were to evaluate the efficacy of corticosteroid injection in the treatment of postarthroplasty trochanteric bursitis, to compare the incidence of risk factors for lateral trochanteric pain in patients who developed trochanteric bursitis and those who did not, and to identify any risk factors for failure of nonoperative treatment. Materials and Methods This study was approved by an Institutional Review Board. All data for the study were obtained from a database that had received approval from our Institutional Review Board. Patient Population From September 1998 through September 2004, 689 primary total hip arthroplasties (current procedural terminology, 27130) were performed at our institution by 5 different surgeons. Of those 689 procedures, 647 (93.9%) were performed with a direct lateral approach, and 42 (6.1%) were performed with a posterior approach; 674 arthroplasties were performed without cement, and 15 were placed via a hybrid technique (a 208

2 Trochanteric Bursitis After Total Hip Arthroplasty Farmer et al 209 cemented femoral component and a cementless acetabulum). Preoperative clinical and radiographic assessment included a detailed history and physical examination, collection of a Harris Hip Score and a Short Form 12 quality of life questionnaire, and anteroposterior pelvis and anteroposterior and lateral hip radiographs. Postoperatively, patients were seen at regular intervals per the individual surgeon's protocol. At each postoperative visit, a detailed patient outcome questionnaire was administered, including collection of a Harris Hip Score and a Short Form 12. Physical examinations at postoperative visits included inspection of incision; analysis of gait, Trendelenburg sign, and hip range of motion; palpation of the lateral hip; assessment for limb-length inequality with clinical and radiographic measurement determination; and a thorough neurovascular examination. Of those 689 arthroplasties, trochanteric bursitis developed in 32 hips (29 patients; 12 men, 17 women), an incidence of 4.6%. Of those 29 patients, 7 (7 hips) were lost to follow-up after treatment of bursitis; the 22 patients (25 hips) with posttreatment follow-up formed our study subgroup. Their mean age was 60 years (range, years); 41% (9 of 22) were men. The diagnosis for performing the 25 arthroplasties was osteoarthritis (21, 84%), osteonecrosis (2, 8%), and developmental dysplasia of the hip (2, 8%). Of the 25 arthroplasties, 23 were performed with a lateral approach (92%) and 2 (8%) with a posterior approach (8%). Demographic data for the overall study population were similar to that of the trochanteric bursitis subgroup: 55% were men; 45% were women; and the presenting diagnoses were osteoarthritis (73%), osteonecrosis (10%), developmental dysplasia of the hip (10%), and rheumatoid arthritis (7%). Measurement Parameters and Definitions We collected data on the following parameters for all patients: age, sex, diagnosis, arthroplasty approach, and preoperative and postoperative Harris Hip Scores. For the 25 patients (22 hips) with lateral trochanteric pain and adequate follow-up, we also recorded leg-length discrepancy, offset, time to injection, number of injections, and response to injections. We used standard postoperative anteroposterior pelvis radiographs to obtain our radiographic measurements. The medial edge of the teardrop was marked as a reference point. Lateralization was defined as the distance of the center of the femoral head from the medial teardrop [1,10,11]. A line was drawn tangential and parallel to the most inferior portion of the ischium. A second line was drawn through the medial edge of both lesser trochanters. The distance between these 2 lines at the lesser trochanter was used as a measure of limb length [12]. The femoral offset was defined as the perpendicular distance from a line drawn down the center of the femur to the center of rotation of the femoral head [13]. The contralateral hip served as the control. The differences in measurements between the operative hip and the contralateral side were recorded. Treatment All patients who underwent total hip arthroplasty and developed mild lateral trochanteric pain without substantial trochanteric tenderness (22 patients, 25 hips) were first treated with a course of nonsteroidal antiinflammatory medications and physical therapy (for at least 4 weeks). Patients with substantial pain or for whom nonsteroidals and physical therapy had failed were treated with an injection of 1 ml of 40 mg of triamcinolone plus 9 ml of 1% lidocaine. The time from total hip arthroplasty to injection for trochanteric bursitis averaged 8.5 months (range, 2-30 months). For the injection, the patient was placed in the lateral decubitus position; and the injection site was localized to the point of maximal tenderness, typically directly lateral to the prominence of the greater trochanter of the proximal femur. A 20-gauge needle was inserted to bone and then withdrawn a few millimeters. The corticosteroid-lidocaine solution then was injected deep to the fascia lata. The anti-inflammatory medications and physical therapy were continued after the injection, and additional injections were offered on an as-needed basis. If the anti-inflammatory medications, physical therapy, and injection(s) failed to resolve symptoms, patients were offered bursectomy and debridement of scar tissue. Statistical Analysis Statistical analysis of the data was performed via JMP software (SAS, Cary, NC). Parametric measurements (eg, age, limb-length discrepancy) were compared with the Student t test. Frequencies were compared via a χ 2 test with Yates correction. Significance was set as P less than.05. Results There were no statistically significant differences in age, sex, or preoperative diagnosis between patients who developed lateral trochanteric pain after total hip arthroplasty and those who did not. Patients with lateral trochanteric pain did show a lower overall improvement in Harris Hip Scores, but this difference was attributable to the differences in the pain component of the score. In the lateral trochanteric pain group, the average Harris Hip Score improved from 51 points (range, points) preoperatively to 85 points (range, points) postoperatively. In the overall hip arthroplasty group, the Harris Hip Score improved from 50 points (range, points) preoperatively to 92 points (range, ) postoperatively. Of the 25 hips (22 patients) with follow-up, 14 received only 1 injection, 7 received 2 injections, 3 received 4 injections, and 1 received 5 injections. The injection(s) resolved symptoms in 20 hips (17 patients) (80%). We defined this group as the responder group. For the 5 hips (5 patients) with continued symptoms (nonresponder

3 210 The Journal of Arthroplasty Vol. 25 No. 2 February 2010 Table 1. Comparison of Responders and Nonresponders Parameter Responders (20 hips) Nonresponders (5 hips) P Value Average age (y) (range) 62 (37-88) 50 (35-76).1 Diagnosis (%) Osteoarthritis Osteonecrosis Developmental dysplasia of the hip Approach (%) Lateral Posterior 10 0 Contralateral total hip arthroplasty (%) Limb-length discrepancy 4.2 (8.9) 4.0 (0.9).1 (SD) * Offset (SD) * 2.1 (7.8) 5.8 (5.5).3 Lateralization (SD) * * Millimeters of difference compared with the contralateral side. group), operative treatment was refused by 3 patients and 2 patients underwent bursectomy; both of the latter 2 had resolution of symptoms. Other causes of lateral hip pain (including lumbar pathology) in the remaining 3 nonresponders were considered, but additional workup was negative. The responder and nonresponder groups were compared in terms of parameters measured: average age, 62 years (range, years) and 50 years (range, years), respectively; use of a lateral approach, 90% (18) and 100% (5), respectively; previous contralateral total hip arthroplasty, 50% (10) and 60% (3), respectively; average limb-length discrepancy, 4.2 mm (SD = 8.9 mm) and 4.0 mm (SD = 0.9 mm), respectively; average offset, 2.1 mm (SD = 7.8 mm) and 5.8 mm (SD = 5.5 mm), respectively; and average lateralization, 0.8 mm (SD = 6.0 mm) and 1.0 mm (SD = 7.1 mm), respectively (Table 1). Although none of the differences were statistically significant, the nonresponder group showed a trend toward a younger age (P =.094) and greater limb-length inequality (P =.089) (Table 1). The incidence of lateral trochanteric pain was almost identical in patients treated with a lateral approach (4.6%) and in those treated with a posterior approach (4.7%). Discussion Lateral hip pain, or trochanteric bursitis, is a known complication of total hip arthroplasty. We found the incidence of this complication to be 4.6%, which was similar to that reported by Iorio et al [1] (4.4% for 543 primary total hip arthroplasties). Iorio et al [1] indicated that a direct lateral approach was a statistically significant risk factor for trochanteric bursitis after total hip arthroplasty. In our study, we did not identify the lateral approach as a specific risk factor; but very few of our arthroplasties (6%) were performed via a posterior approach, making a comparison of incidence of lateral trochanteric pain by surgical approach difficult. A larger sample of patients treated with a posterior approach would be needed to state definitively that there was no relation between the approach and trochanteric bursitis in our study group. A few possible explanations for the association of trochanteric bursitis and the lateral approach have been proposed. The surgical incision typically is located directly over the greater trochanter and is carried deep through the fascia lata and through the trochanteric bursa [14]. Postsurgical scar tissue formation in this region likely contributes to the association of this approach and trochanteric bursitis. In addition, any abductor weakness caused by a transgluteal approach or overtensioning of the fascia lata may increase the risk of trochanteric bursitis with this approach [14]. Recently, a magnetic resonance imaging study noted a statistically significant increase in gluteus medius and minimus tendinopathy in all patients with trochanteric bursitis. The posterior approach avoids these tendons, which may offer another plausible reason for the decreased incidence noted in this group [15]. In our study, 14 of the 25 injected hips (56%) required only 1 injection, a finding similar to that of a study of nonarthroplasty-related trochanteric bursitis that showed that 46 of 75 patients (61%) were symptom-free 6 months after 1 injection [16]. Another study showed that as many as 25% (9 of 36) of patients may have a recurrence of symptoms after corticosteroid injection for trochanteric bursitis [6]. Our recurrence rate was 44% (11 of 25 hips required additional injection). Persistent symptoms may be caused by inaccurate placement of the corticosteroid. A recent fluoroscopic study showed that there was only a 45% accuracy rate of corticosteroid placement into the trochanteric bursa with a single injection [7,17]. In our study, it is possible that some additional injections were necessary because, in previous injections, the corticosteroid had not been placed accurately at the site of the inflammation. We found that corticosteroid injection(s) resolved symptoms in 80% (20 of 25) of the hips and that 20% (5 of 25) had continued symptoms or required bursectomy and excision of scar tissue. All 5 nonresponders had a minimum of 2 corticosteroid injections. Schapira et al [7] found a 90.3% (65 of 72 hips) rate of resolution of symptoms after treatment with corticosteroid injection(s) for atraumatic trochanteric bursitis. Such findings show that trochanteric bursitis after total hip arthroplasty has a response to corticosteroid treatment similar to that of nonarthroplasty-related trochanteric bursitis. Although Lievense et al [18] showed no correlation of age and response to treatment of nonarthroplasty-related trochanteric bursitis, a comparison of responders and nonresponders in our study showed that the responders were, on average, 12 years older (range, years)

4 Trochanteric Bursitis After Total Hip Arthroplasty Farmer et al 211 than the nonresponders. This difference was not statistically significant, but it does indicate a trend toward significance (Table 1). It is possible that younger patients are more active and thus are more prone to recurrence of symptoms or continued inflammation. Additional studies with larger study groups and that quantify postoperative activity levels may help explore this issue. Although no nonresponder had undergone a posterior approach, we found no statistical significance between the groups in terms of the type of approach and response to treatment because of the small number of patients studied (Table 1). In addition, we found no significant difference between the groups in terms of the primary diagnosis or presence of contralateral total hip arthroplasty (Table 1). Other authors have hypothesized that increased offset of the stem and lateralization of the femoral head may tighten the iliotibial band and predispose patients to lateral hip pain after total hip arthroplasty [1]. In our study, we did not find any association between offset and lateralization and the response to treatment (Table 1). However, no patient in our study had severe lateralization or offset; and therefore, we cannot comment on the relationship between severe offset and bursitis. Lievense et al [18] noted a correlation between bilateral symptoms and continued unilateral symptoms despite appropriate treatment. In our study, 3 patients had bilateral symptoms: 1 patient had resolution of symptoms bilaterally, but the other 2 patients had only unilateral resolution. In addition, we did not find any association between bilateral hip arthroplasties and failure of nonoperative treatment (Table 1). Leg-length discrepancy is a common problem after total hip arthroplasty [19]. It is hypothesized that alterations in limb lengths affect tensioning of the soft tissues around the hip and gait mechanics. This combination could predispose patients to trochanteric pain and bursitis [1]. Iorio et al [1] failed to find an association between limblength inequality and trochanteric bursitis; but our nonresponders had greater limb-length inequality than did responders (Table 1), although the difference was indicative of a trend rather than statistical significance. In addition, we did not compare limb-length discrepancies between those who developed trochanteric bursitis and those who did not. Additional studies with larger sample sizes and comparisons to unaffected patients may help clarify the association between limb-length inequality and trochanteric bursitis. Our study showed that trochanteric bursitis after total hip arthroplasty is uncommon (less than 5% of cases) and that it occurs more frequently after a lateral approach than after a posterior approach. Treatment with corticosteroid injection usually is effective, but multiple injections may be necessary. A small percentage of patients may require more aggressive intervention, including operative treatment. Patients young in age and with increased leg-length inequality may be more susceptible than others to failure of nonoperative management. Additional studies with larger sample sizes and longer follow-up are warranted. Acknowledgment The authors gratefully acknowledge the guidance of David S Hungerford, MD, during this investigation. References 1. Iorio R, Healy WL, Warren PD, et al. Lateral trochanteric pain following primary total hip arthroplasty. J Arthroplasty 2006;21: Saito S, Ryu J, Oikawa H, et al. Clinical results of Harris- Galante total hip arthroplasty without cement. Follow-up study of over five years. Bull Hosp Joint Dis 1997;56: Vicar AJ, Coleman CR. 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5 212 The Journal of Arthroplasty Vol. 25 No. 2 February Shbeeb MI, O'Duffy JD, Michet Jr CJ, et al. Evaluation of glucocorticosteroid injection for the treatment of trochanteric bursitis. J Rheumatol 1996;23: Cohen SP, Narvaez JC, Lebovits AH, et al. Corticosteroid injections for trochanteric bursitis: is fluoroscopy necessary? A pilot study. Br J Anaesth 2005;94: Lievense A, Bierma-Zeinstra S, Schouten B, et al. Prognosis of trochanteric pain in primary care. Br J Gen Pract 2005;55: Turula KB, Friberg O, Lindholm TS, et al. Leg length inequality after total hip arthroplasty. Clin Orthop Relat Res 1986;202:163.