Introduction

Background: Trochanteric bursitis is a common and poorly understood complication following total hip arthroplasty (THA). The purpose of this study was to evaluate the incidence of symptomatic trochanteric bursitis and the change in hip offset among THA patients before and after the introduction of robotic assistance.

Primary tuberculous bursitis was a relatively frequent manifestation of the disease before the antituberculosis drug era. Nowadays, it is considered a rare condition; it accounts for 1–2% of all musculoskeletal tuberculosis. The diagnosis and treatment of tuberculous bursitis may be delayed because the paucity of symptoms, its indolent clinical course and a low clinical suspicion. A 50-year-old patient with tuberculous trochanteric bursitis is reported.

A 50-year-old woman was referred to our department to investigate a persistent pain in her left hip with 6 months duration. She was afebrile. The examination revealed a diffuse swelling from the buttock through the thigh, notable over the trochanter, but no sign of acute inflammation such as heat and redness. Her past medical and family histories revealed no previous tuberculosis.

Plain films of the left hip showed a partial destruction of the margin of the greater trochanter, lytic foci in the underlying bone and a small focus of calcification in the adjacent soft tissues. A computed tomogram showed a soft tissue mass and demonstrated the relationship with the trochanter. We performed a needle biopsy which revealed granulomatous tissue. The patient underwent complete excision of the bursa and curettage of the surface of the trochanter. The postoperative course was uneventful. Mycobacterium tuberculosis was isolated and definitive diagnosis of tuberculous bursitis was made. There was no evidence of concomitant tuberculosis at other musculoskeletal sites. The patient completed a treatment with rifampicin and etambutol for 6 months.

There has been a complete resolution of the symptoms after 3 months and no recurrence after 4 years of follow-up. On plain radiograph the remodeling of the bone structure is clearly visible.

Tuberculosis in the region of the greater trochanter is extremely rare. This rarity leads orthopedic surgeons to neglect this potential diagnosis, resulting in a delay in treatment. The pathogenesis of tuberculosis of the greater trochanteric area has not been well defined. The incidence of concomitant tuberculosis at other musculoskeletal sites, as well as the lung, is approximately 50%. Both hematogenous infection and propagation from other locations are reasonable explanations. Surgical intervention is mandatory for cure and the use of several antituberculosis agents is a standard approach.

Introduction

Trochanteric bursitis is described as pain over the lateral side of the hip and thigh. The usual treatment is rest, administration of NSAIDs and injection of local anaesthetic and corticosteroid. Occasionally it is resistant to these measures.

Introduction: Extracorporal Shock Wave Therapy (ESWT) has become a useful adjunct for the treatment of various musculo-skeletal inflammatory conditions.

The aim of the study is prospective assessment of the efficacy of ESWT for the treatment of recalcitrant greater trochanteric bursitis (GTB).

Material and Methods: Prospective evaluation and follow-up of fourteen patients with persistent GTB two of them with bilateral problem. All the patients failed to response to conventional treatment with oral NSAID’s, physiotherapy, US and more than one steroid injection to the grater trochanter region. All patients underwent compete physical examination. A Comprehensive VAS Score (grading from 0–10) which were obtained prior to therapy and at follow-up. ESWT was applied in six consequitive courses each of 1500 impulses of 0.32mj/mm^2 to the lateral side of the grater trochanter region.

Results: Mean age of 60.6 ± 11.6 (mean ± SD) years (range 81 to 38 years). Mean duration of symptoms 14.2 ± 8.1 months, up to 37 months. Mean VAS dropped from 7.9 ± 0.9 to 1.6 ± 0.8 (p< 0.0001). There were no side effects except minimal local discomfort during the session time.

Conclusion: ESWT is an effective treatment for recalcitrant GTB, with minimal side effect.

31 patients, between the ages of 59 and 74 years, were referred to one onrthopaedic consultant as trochanteric bursitis. All were females. Of these 7 patients were diagnosed as osteoarthritis of the hip or underwent further investigations for spinal conditions. 24 patients were clinically diagnosed as trochanteric bursitis. All these patients had ultrasound examination of the hips by a radiologist with a special interest in musculoskeletal diseases. Except for one patient the rest had either gluteus medius inflammation or tears with or without involvement of gluteus minimus. All these patients with positive findings had 80mg of depomedrone injection under USG guidance. At 6 weeks follow up 21 had complete relief of symptoms. 4 had recurrence of symptoms at 3 months when they had another dose of depomedrone und USG guidance. At one year 18 were free of symptoms and the 3 with some recurrence of symptoms did not want any intervention.

Discussion: Etiology of greater trochanteric pain syndrome has been a source of considerable debate. Empirical treatment with ‘blind’ steroid injection is the usual course of action. In unresolving trochanteric bursitis excision of trochanteric bursa has been advocated. Gluteus medius and minimus tears have been referred to as rotator cuff tears of the hip (1). Our study shows an association between trochanteric bursitis and ‘rotator cuff tears of hip’. Ultrasound guided steroid injection can give a better success rate of ‘hitting the right spot’. Further investigations are required to identify whether this association could be a cause and effect relationship.

Introduction: Trochanteric bursitis is a common hip problem that can be refractory to treatment. The available modalities of treatment can be less effective. We evaluated the use of extra-corporeal shockwave therapy treatment for trochanteric bursitis.

Methodology: 22 patients with the clinical and radiological (in 6 patients) diagnosis of trochanteric bursitis were treated in a dedicated shockwave therapy clinic using Swiss dolocast radial shockwave therapy machine. 3 sessions of treatment were given one week apart, delivering 2000 impulses at 10 Hz at each session. Patients were evaluated prior to treatment, 3 months, 6 months and 12 months following their treatment. The visual analogue score (VAS) was used in all patients pre and post treatment. Hip disability and osteoarthritis score (HOOS) was performed post-treatment.

Results: Between December 2005 and November 2008 22 patients were treated for symptoms of trochanteric bursitis. There were 17 women and 5 men. The average age was 55.8 years (range 33–76 years). 6 patients had proven increase signal on MRI scan the rest were mainly clinical diagnosis and after a limited response to steroid injections. Their VAS improved from 10 to 5. Their post-treatment HOOS score averaged 255.

Of the 6 patients who had MRI proven increased signal 5 patients had significant improvement. The average improvement in the VAS was 10 to 2.3 and their HOOS scores were 349.2 (range 427–243).

Conclusion: Though the number of patients in this study is only 22 it seems that radial shockwave therapy treatment for trochanteric bursitis is promising, especially on those who have got high signal on MRI scans.

We describe a previously unreported technique of Z-lengthening for the treatment of refractory trochanteric bursitis and review the long-term outcomes for this procedure.

Fifteen patients (17 hips) were diagnosed with trochanteric bursitis based on clinical criteria. These patients were found to be unresponsive to conservative treatment including multiple corticosteroids injections. “Snapping Hips” were excluded. All went on to have bursectomy and Z- lengthening of the iliotibial band.

Harris Hip Scores were evaluated for before and after their operation as well as a standardised baseline questionnaire and examination.

At mean follow up of 47 months following Z-lengthening, eight patients reported excellent results with complete resolution of symptoms, eight had good results with symptoms improved and one had a poor result. One patient required secondary repair of a tear in the tendon of gluteus minimus with a subsequent excellent result. The mean Harris Hip Score improved from 46 to 82 (p< 0.05).

Bursectomy and Z-lengthening has been shown to be an effective and long-term operative solution for the treatment of refractory trochanteric bursitis when conservative measures have failed. Although the majority of patients had a successful outcome, not all respond well to this procedure and careful patient selection is recommended as well as a pre-operative MRI to rule out concomitant pathology such as a tear in the Gluteus medius or Gluteus minimus.

Trochanteric bursitis is initially treated with local anaesthetic and corticosteroid injections but when this fails there are few interventions that relieve the symptoms.

We report a new surgical technique for refractory trochanteric bursitis in 43 patients. Fourteen patients had developed trochanteric bursitis after primary total hip arthroplasty (THA), 6 after revision THA, 17 for no definable reason (idiopathic) and 7 after trauma.

Follow up ranged from six months to 15 years (mean five years). Outcome was measured by pre and post operative Oxford Hip Scores. The mean post operative decreases were 23 points in traumatic cases, 13 in idiopathic and 13 for patients after primary THA. A mean increase of 3 was observed in patients after revision THA.

The operation relieved symptoms in 75%. The outcome depended on aetiology. 100% of traumatic, 88% of idiopathic and 64% after primary THA were successful. All operations after revision THA were unsuccessful.

This is the largest series of a single surgical technique for refractory trochanteric bursitis and the only one to subdivide the outcome by aetiology. Transposition of the gluteal fascia is indicated in patients with idiopathic, traumatic and post primary THA trochanteric bursitis, but not after revision THA.

Introduction: The technique of endoscopic bursectomy is described. Results are evaluated and compared to “open” surgery.

Patients and methods: Data were registered from case records of all relevant patients operated on in the period 1/1/1994–30/6/97. Patients were interviewed by telephone at follow up.

Results: Ten female and 60 male patients had been operated on, 19 patients endoscopically (EN), 19 with excision and primary suture (EPS), and 32 with incision (IN). In the EN group 14/19 of the bursites were infected, in the EPS and IN groups figures were 5/19 and 26/32 respectively. Operation time was shorter and hospitalization time longer in the IN group. Healing was fastest in the EN group, no patients were readmitted or reoperated. One patient in the EPS and 6 in the IN group were readmitted. Twenty two patients in the IN group were reoperated between one and seven times.

Conclusion: Endoscopic resection is safe and effective.

Aim

The optimal surgical approach for patients hospitalized for moderate to severe septic bursitis is not known, and there have been no randomized trials of a one-stage compared with a two-stage (i.e., bursectomy, followed by closure in a second procedure) approach. Thus, we performed a prospective, non-blinded, randomized study of adult patients hospitalized for an open bursectomy.

Aim: To present the results of trochanteric reduction osteotomy for treatment of resistant trochanteric bursitis.

Methods: Trochanteric reduction osteotomy was performed on ten patients. All patients had been conservatively managed for at least one year with analgesics, anti-inflammatory medications and local steroid injections. All these measures however failed to relieve patients symptoms. The senior author performed trochanteric reduction osteotomy and the osteotomy site was fixed using screws. Patients were assessed pre and postoperatively with a minimum follow-up of six months using oxford hip and modified UCLA scores.

Results and Conclusions: Patient demography, patient selection, surgical technique and results will be presented. All patients were followed-up for a minimum period of six months at regular intervals before being discharged. Early results are very encouraging. Trochanteric reduction osteotomy is a good treatment option in the management of resistant GT bursitis who do not respond to conservative treatment as most of the patients were disabled before operation.

Introduction: Trochanteric bursitis (TB) in association with increased femoral offset components in THA has not previously been reported. We report 15 cases of postoperative TB, all of whom were noted to have high offset femoral implants. Increasing awareness of this complication when inserting femoral components is an important consideration for the arthroplasty surgeon, emphasizing the need for preoperative templating.

Methods: We retrospectively reviewed casenotes and postoperative radiographs patients attending outpatients following THA, with lateral hip pain. A diagnosis of trochanteric bursitis was made in individuals complaining of lateral hip pain, worse on exercising, and tenderness over the trochanter. The presence of a high offset femoral component was noted from casenotes radiographs. Patients with pre-existing TB, recent local trauma, or inflammatory disease which may contribute to TB, were excluded.

Results: 15 cases were identified in a 3 year period. Female to male ratio 1.3:1. The mean age was 68 yrs with a range of 54–81yrs. 7/15 cases (46%) underwent posterior approach to the hip, 8/15 (54%) underwent a Hardinge lateral or modified lateral approach. All patients had clinical features of TB at first postoperative follow up. Mean time to onset of symptoms was 7.2 months, range 2–12 months. All femoral implants had 5mm offset or greater. Postoperative X-rays showed a mean increase in offset of 10.2mm, range 3–18mm.

Discussion: The results indicate that an increase in femoral offset may increase a patient’s risk of trochanteric bursitis, following THA. The data suggest the operating surgeon should consider carefully the use of increased-offset implants, particularly in those at a higher risk or TB e.g inflammatory disorders. This study emphasises the importance of preoperative templating in total hip arthroplasty.

Introduction: Trochanteric bursitis rarely needs surgical treatment. A distal lengthening procedure has been described.

Purpose: To analyze the outcomes of two different surgical techniques: proximal and distal lengthening of the fascia lata.

Materials and methods: Median instead of average was used for the quantitative variables. Twenty one patients (23 hips) were treated between October 1999 and February 2006. They were divided into two groups and their previous medical and surgical history was collected. The proximal Z-plasty group included 10 hips with a median age of 54 years; median body mass index (BMI) was 28.5 and median time from onset of symptoms till surgery was 36 months. The distal Z-plasty group included 13 hips, median age was 54.6 years; median BMI was 26.3; and evolution till surgery was 18 months. Harris hip score, verbal analog scale for pain (VAS) and a Lickert satisfaction scale were used.

Results: In the “proximal group” the Harris hip score improved from 61 to 77.5. VAS improved from 82.5 to 27.5 and as regards the Lickert score 3 hips were very satisfied; three were satisfied; two hardly satisfied; one dissatisfied and one very dissatisfied. Two seromas occurred after surgery. In the “distal group” Harris score improved from 63 to 91. VAS improved from 90 to 10 and the Lickert scale gave 5 very satisfied hips; 4 satisfied; none hardly satisfied; 4 dissatisfied and none was very dissatisfied. There was a seroma after surgery.

Conclusion: Despite the low number of cases, distal Z- plasty showed better results than the proximal technique in the treatment of trochanteric bursitis.

This study describes a safe endoscopic technique for decompression of trochanteric bursa and presents the results of this procedure.

Fifteen patients who had failed non-operative treatment for trochanteric bursitis were treated by endoscopic lengthening of fascia lata (FL) and trochanteric bursectomy. Two patients had also failed open decompressions performed at another institution prior to their endoscopic surgery. All patients took part in questionnaires pre-operatively and at three months and twelve months. A two-portal endoscopic procedure was performed in all subjects. A Cruciate incision was made in the FL hence lengthening it in three dimensions. A trochanteric bursectomy was then performed using a mechanical shaver.

No patients were lost to follow up. At last review 14 patients rated their result as excellent and one patient had a fair result. There were no complications. The modified Harris hip score improved from 45 to 60, Non-arthritic hip score improved from 45 to 64 and SF12 score improved from 31 to 34.

Endoscopic lengthening of FL and trochanteric bursectomy is a safe and effective procedure in relieving the symptoms of persistent trochanteric bursitis.

Introduction: The red, hot swollen knee is commonly seen in the A& E department and can present a diagnostic dilemma for the casualty officer. While superficial cellulites and bursitis are the most common diagnoses, anxiety is induced by the spectre of septic arthritis. The potential sequalae from aspirating a knee through infected superficial tissues further emphasise the importance of making an accurate clinical diagnosis.

The lymph drainage of the superficial tissues of the lower limb is via lymphatics that accompany the long saphenous vein and drain to the lower group of the superficial inguinal nodes. Drainage from the knee joint is to a popliteal node situated between the knee joint capsule and the popliteal artery. Efferents from this node ascend in close relation to the femoral vessels and drains to the deep inguinal nodes. We hypothesise that the differences in lymphatic drainage mean that palpable inguinal nodes are more likely with superficial infections than with septic arthritis. We reviewed the clinical findings in a group of patients with superficial or deep infections to test this theory.

Patients and Methods: From January 1995 until June 2000, twenty-seven patients were admitted with septic arthritis of the knee and fifty-one with superficial cellulites or bursitis about the knee. The former were diagnosed on the basis of clinical findings and a knee aspirate, the latter on clinical findings and response to treatment. The presence or absence of palpable inguinal lymph nodes was determined and compared for each diagnostic group.

Results: Joint aspirates from the group with septic arthritis grew organisms in twenty patients (staph aureus in 19, strep pneumoniae in one). The remaining seven patients had no growth but purulent fluid on aspirate with leukocyte counts in excess of 50,000/mm³. Six patients had rheumatoid arthritis and two were HIV positive IVDA’s but the rest had no pre-disposing factors. The average age was 52 (range 16–83). All were treated with arthroscopic washout (average 2.2/patient) and antibiotic chemotherapy.

In the superficial infection group 28 (56%) had pre-patellar bursitis and 23 (54%) cellulites. All were treated with antibiotics while eight of the bursitis group required incision and drainage. In the patients with superficial infection 32 (63%) had palpable inguinal lymphadenopathy while no patient with septic arthritis of the knee had palpably enlarged inguinal lymph nodes. This result is highly statistically significant (p< 0.01).

Discussion: It is well recognised that neoplastic or inflammatory conditions of the superficial tissues of the lower limb may be associated with inguinal lymphadenopathy. A similar association for septic arthritis of the knee has not to our knowledge been described. Our study would suggest that palpably enlarged lymph nodes are unusual in this condition. While it is worth emphasizing that the presence of lymph nodes does not rule out absolutely the possibility of septic arthritis, their presence or absence may be useful in differentiating superficial from deep infections about the knee.

Objectives

Inflammation of the retrocalcaneal bursa (RB) is a common clinical problem, particularly in professional athletes. RB inflammation is often treated with corticosteroid injections however a number of reports suggest an increased risk of Achilles tendon (AT) rupture. The aim of this cadaveric study was to describe the anatomical connections of the RB and to investigate whether it is possible for fluid to move from the RB into AT tissue.

The aim of this review is to evaluate the current available literature evidencing on peri-articular hip endoscopy (the third compartment). A comprehensive approach has been set on reports dealing with endoscopic surgery for recalcitrant trochanteric bursitis, snapping hip (or coxa-saltans; external and internal), gluteus medius and minimus tears and endoscopy (or arthroscopy) after total hip arthroplasty. This information can be used to trigger further research, innovation and education in extra-articular hip endoscopy.

Residual pain after THR can have a number of causes. Unless there was a major intraoperative inadequacy or early deep infection provided the patient indicates the greater part of the preoperative arthritic pain has been relieved and if other major clinical and radiological features are satisfactory remaining discomfort is all too easily attributed to a muscular origin with reassurances it will settle down! The senior authors attention was drawn to intrusive groin pain by a patient who had an otherwise uneventful bilateral (same sitting) THR. Right groin pain remained particularily marked on moving the leg getting in and out of her car on the drivers side.Clinical assessment Xray & CT scan & CT guided diagnostic injection suggested the symptoms were due to Psoas irritation perhaps due to a cement prominence underneath a proud edge of a flanged Charnley acetabular component. Through a direct anterior exposure this was shown to be so. There was evidence of Psoas Bursitis with a granular appearance.Symptoms were relieved by removing the flange and cement prominence and performing a partial psoas bursectomy and partial psoas tenotomy. Six similar cases are described. How to avoid or treat this annoying minor complication of a generally successful operation by attention to detail is discussed

Shockwave treatment in our unit is provided in conjunction with our Urological colleagues. Shock Wave Therapy has been used as a last option in patients with difficult and chronic Orthopaedic conditions with an informed consent for all patients. Material and Methods: 28 patients from Ealing Hospital and West Middlesex Hospital were referred to The Lithotripsy unit at Charing Cross Hospital for Shock wave therapy. Patients were consented by the Orthopaedic surgeon and the treatment was administered by urologist. The cases included:. 4 Humeral fractures: 1 Case in HIV +ve 19 years old. 5 Femoral non-union: 1 case bilateral in Osteogenesis imperfecta. 4 Tibial non-union: 1 Recurent Fracture in 65 years old man. 2 Osteochondritis of the Talus. 2 Osteochondritis of the knee. 4 Scaphoid fractures: 1 case had been fixed and grafted. Medial Epicondyle fracture non union. 5. th. Metacarpal Fracture. Trochanteric Bursitis. Tennis Elbow. 4 Planter fasciitis. – The Shock wave Machine used is Storz SLX – F2 Electromagnetic shock wave generator which focus the shock wave low energy high frequency in focal zone with no harm to other tissues. Frequency 4 htz = 4 shockwave/sec. – Energy level 1–3 generate pressure value in the focal area of 5–30 megapascal. – Size of focal zone 9X 50 mm or 6X 28 mm. – Total shock wave applied per session 2000 to 3000 shock. – large focus and small focus were used in fracture of large bones and small bones respectively. Most of cases required 2–3 session with 4–6 weeks interval. – in Soft tissue Treatment Less energy was used and patients required 1 to 2 sessions. Results: There was complete resolution of symptoms in the 4 cases of soft tissues. – Clinical and radiological union in 3 of the 4 Humeral Fracture including HIV+ve and in 2 of 3 tibial fracture and 1 of 2 scaphoid. – 50% pain relief in Psedo arthrosis. – Union is promoted by Cellular stimulation and pain relief is by unknown mechanism but explained by increase vascularity and neuro-modulation. – None of the patient’s have so far required subsequent operative interventions, several had residual symptoms. Discussion: Shock wave therapy is a new consevative treatment modality used in orthopaedic as the last option before surgery but there is a need for RCT