Trochanteric Pain and Total Hip Arthroplasty

A Systematic Review of the Literature

Daniel Axelrod, MD, MSc (Cand); Kim Madden, PhD; Habeeb Khan, MBBS, BScPA; Laura Banfield, MLIS, MHSc; Mitchell Winemaker, MD, FRCSC; Justin DeBeer, MD, FRCSC; Thomas J. Wood, MD, FRCSC

Disclosures

Curr Orthop Pract. 2020;31(4):400-407. 

In This Article

Abstract and Introduction

Abstract

Background: Total hip arthroplasty (THA) is one of the most common surgical procedures. Although THA surgeries are typically very successful, between 3% and 17% of all patients experience trochanteric pain after surgery. There is little high-quality evidence on this disorder, especially after total hip arthroplasty. The purposes of this review were to describe the prevalence, treatments, prognosis, risk factors, and diagnostic methods available for trochanteric pain among preoperative or postoperative primary THA patients.

Methods: The authors conducted a systematic review of trochanteric pain among THA patients. PUBMED, EMBASE, CINAHL, and the Cochrane Library were searched to identify relevant articles. Two reviewers systematically screened studies and extracted data independently in duplicate. This study presents descriptive statistics and pooled prevalence of trochanteric pain.

Results: We included 36 studies with 7826 patients (mean age of 62 yr, 59% female). The prevalence of trochanteric pain was reported in 25 studies, with a mean prevalence of 3.8% (95% CI 3.3% to 4.4%). Methods of treatment for trochanteric pain included corticosteroid injections, bursectomy, and iliotibial (IT) band lengthening. Risk factors for trochanteric pain were inconsistently reported, but those most commonly listed were female gender and postoperative leg-length discrepancy.

Conclusions: Approximately one in 25 patients who has undergone standard THA experiences postoperative trochanteric pain. With low certainty, the results of this review suggest the surgical approach may not influence incidence of trochanteric pain. The heterogeneity in both diagnostic modalities reported and in treatment options suggests that further prospective research is required to better inform treatment decisions for this common condition.

Level of Evidence: Level III.

Introduction

Total hip arthroplasty (THA) is one of the most common operations in Canada, with an estimated 59,000 surgeries performed from 2017 to 2018.[1] Over the last 5 years, the number of THAs that were performed has increased by 17.4%. These procedures were mostly successful; however, 3% to 17% of patients suffered from trochanteric pain (TP) after THA, and the nature of the relationship to the surgery is unclear. The incidence of trochanteric pain may vary depending upon the approach that is used.[2,3]

Trochanteric pain, also referred to as trochanteric pain syndrome, greater trochanteric pain syndrome, trochanteric bursitis and other terms,[4] is characterized by pain on the lateral side of the hip that does not involve the hip joint. It can be elicited clinically by palpation over the greater trochanter. Though diagnosis can be made with clinical examination alone, an ultrasound or MRI can be used as an adjunct.[5] However, as concomitant degenerative abductor tears are often present, and pain is poorly localized, it can become difficult to associate MRI findings with patient symptoms.

Although the cause of trochanteric pain is unclear, it is thought to be caused by repetitive microtrauma to the abductor musculature, which is caused by changes in hip biomechanics after THA.[6] Other causes include direct trauma to the gluteus medius and minimus muscles and tendons and inflammation of the bursa overlying the greater trochanter; however, histopathological studies often find little evidence of inflammation.[7] Patient factors reported to influence the incidence of trochanteric pain include higher comorbid status, history of smoking, and patient gender.[8] The pain associated with trochanteric pain can be disabling, sometimes requiring surgical intervention.[9] However, these interventions may carry the risk of significant complications including infection of the implant and subsequent revision arthroplasty.

Management options for trochanteric pain are typically nonoperative and comprise a combination of either unstructured or targeted physiotherapy, corticosteroid injections and platelet-rich plasma (PRP).[10] However, there exists a paucity of high-quality evidence surrounding the use of these modalities to treat trochanteric pain with scattered reports in the literature. Moreover, there is lack of a collective opinion from clinicians on the treatment of this common problem.

The objectives of this review were to describe, among preoperative or postoperative primary THA patients: (1) the prevalence of trochanteric pain, (2) the risk factors for trochanteric pain, (3) the methods available for diagnosing trochanteric pain, (4) the available treatments for trochanteric pain, and (5) clinical outcomes after trochanteric pain (prognosis).

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