Incidence of greater trochanteric pain syndrome in patients suspected for femoroacetabular impingement evaluated using magnetic resonance arthrography of the hip

Good functional outcomes after endoscopic treatment for greater trochanteric pain syndrome

PURPOSE

Greater trochanteric pain syndrome (GTPS) is a term covering different conditions generating lateral hip pain. Recalcitrant cases may require surgery but there are only a few studies evaluating endoscopic treatment. This study aimed to evaluate the outcome of endoscopically treated GTPS at minimum two years postoperatively using patient-reported outcome measures (PROMs), and to assess the complication rate associated with endoscopic surgery.

METHODS

A total of 33 patients, mean age 43.2 years, 88% women, with a mean symptom duration of 3.5 years, were included in the study. A total of 36 operated hips were included. Pre- and at minimum two years postoperatively the patients completed questionnaires consisting of the International Hip Outcome Tool (iHOT-12) and the Hip Sports Activity scale (HSAS), the Visual analogue scale for overall hip function (VAS-OHF), the Copenhagen Hip and Groin Outcome Score (HAGOS), the EuroQoL-5 Dimension Questionnaire (EQ-5D) and the EQ-VAS. Complications were assessed using the Clavien-Dindo classification.

RESULTS

Median follow-up time was 24.5 months postoperatively. Statistically significant improvements were seen for the following PROMs (p < 0.05); iHOT-12 (36.3 vs 54.0), HAGOS different subscores (40.8 vs 59.0, 46.5 vs 62.6, 29.9 vs 53.1, 33.5 vs 51.4, 20.7 vs 41.4, 23.4 vs 43.3), EQ-VAS (55.9 vs 63.3) and EQ-5D (0.392 vs 0.648). VAS-OHF and HSAS did not reach significance. There was a 71% satisfaction rate with the surgery. Three Clavien-Dindo grade 1 and one grade 2 complications were registered postoperatively, with 41% of patients achieving PASS for iHOT-12 at two years follow-up.

CONCLUSION

Endoscopic surgery for greater trochanteric pain syndrome improved patient-reported outcomes and the procedure was associated with low risk of complications.

LEVEL OF EVIDENCE

Level IV.

A Novel Treatment Approach of Ultrasound-Guided Radiofrequency Ablation of the Greater Trochanteric Sensory Nerve for Recalcitrant Greater Trochanteric Pain Syndrome

This report describes a novel technique for the treatment of recalcitrant greater trochanteric pain syndrome (GPTS) by radiofrequency ablation (RFA) of the greater trochanteric sensory nerve (GTsn). Here, we describe one patient suffering from recalcitrant GTPS treated with RFA of the GTsn in the outpatient pain clinic setting. Over the eight months subsequent to treatment, the patient was monitored for changes in the Numerical Pain Rating (NPR) and Lower Extremity Functional Score (LEFS). The patient demonstrated meaningful symptomatic and functional improvement as measured by both NPR and LEFS. GTsn RFA may be a viable treatment option for recalcitrant GTPS. Larger comparative trials are needed to establish improved results over conventional treatments.

Pathogenesis and contemporary diagnoses for lateral hip pain: a scoping review

PURPOSE

Recent advances in diagnostic imaging techniques and soft tissue endoscopy now allow for precise diagnosis and management of extra-articular hip pathology. The aim of this scoping review is to present an evidence-based update of the relevant literature focussing only on the pathoanatomy, clinical assessment and the diagnosis of pathology in the peritrochanteric space.

METHODS

A literature search was performed on PubMed to include articles which reported on the anatomy and diagnosis of greater trochanteric pain syndrome, trochanteric bursitis, gluteus medius tears and external snapping hip syndrome.

RESULTS

A total of 542 studies were identified, of which 49 articles were included for full text analysis for the scoping review. Peritrochanteric space pathology can be broadly classified into (1) greater trochanteric pain syndrome (GTPS), (2) abductor tears and (3) external snapping hip syndrome. Anatomically, gluteus medius, gluteus minimus and tensor fascia lata work in conjunction to abduct and internally rotate the hip. The anterolateral part of the gluteus medius tendon is more prone to tears due to a thin tendinous portion. Increased acetabular anteversion has also been shown to be associated with gluteal and trochanteric bursitis. In terms of clinical examination, tests which were found to be most useful for assisting in the diagnoses of lateral hip pain were the single-leg stance, resisted external derotation of the hip, hip lag sign and the Trendelenburg's test. Dynamic ultrasound along with guided injections and MRI scan do assist in differentiating the pathology and confirming the diagnosis in patients presenting with lateral hip pain. Finally, the assessment of baseline psychological impairment is essential in this group of patients to ensure outcomes are optimised.

CONCLUSION

Lateral hip pain used to be a poorly defined entity, but advances in imaging and interest in sports medicine have led to a better understanding of the pathology, presentation and management of this cohort of patients. A thorough appreciation of the anatomy of the abductor musculature, specific clinical signs and imaging findings will lead to an appropriate diagnosis being made and management plan instituted.

LEVEL OF EVIDENCE

IV.

Arthroscopic Treatment for Femoroacetabular Impingement Syndrome with External Snapping Hip: A Comparison Study of Matched Case Series

OBJECTIVE

To determine the effectiveness of hip arthroscopy combined with endoscopic iliotibial band (ITB) release in patients with both femoroacetabular impingement (FAI) syndrome and external snapping hip (ESH).

METHODS

Retrospectively review the preoperative and minimum of 2-year follow-up data of patients with both FAI syndrome and ESH who underwent endoscopic ITB release during hip arthroscopy (FAI + ESH group) from January 2014 to December 2018. The same number of age- and gender-matched FAI syndrome patients without ESH undergoing hip arthroscopy were enrolled in the control group (FAI group). Patient-reported outcomes (PROs) including international Hip Outcome Tool (iHOT-33), modified Harris Hip Score (mHHS), visual analog scale for pain (VAS-pain), and abductive force of affected hip at 3 month and 2 years postoperatively were comparatively analyzed. The VAS-satisfaction score of two groups at 2 years postoperatively were also analyzed.

RESULTS

The prevalence of ESH in FAI syndrome patients undergoing hip arthroscopy in our institution was 5.5% (39 of 715 hips), including nine males (10 hips) and 29 females (29 hips). The mean age at the time of surgery was 32.1 ± 6.9 years (range, 22-48 years). According to inclusion and exclusion criteria, 23 patients were enrolled in FAI + ITB group. Twenty-three age- and sex-matched FAI syndrome patients were enrolled in FAI group. At 24 months postoperatively, no patient still suffered ESH symptoms and painful palpation at lateral region in FAI + ITB group. The iHOT-33, mHHS, and VAS-pain score of patients in FAI + ESH group were significantly severer than patients in FAI group preoperatively (41.6 ± 7.5 vs 48.8 ± 7.2, 54.8 ± 7.2 vs 59.2 ± 6.9, 5.5 ± 0.9 vs 4.7 ± 1.0; P < 0.05), while there was no significant difference in these scores between the patients in FAI + ESH group and FAI group at 3-month and 24-month follow-up (73.6 ± 8.5 vs 76.1 ± 6.9, 85.3 ± 7.8 vs 84.2 ± 6.6, 0.8 ± 0.9 vs 0.6 ± 0.9; P > 0.05). At 3 months after surgery, the abductive force of operated hip was significantly smaller than that in FAI group (82.4 ± 12.4 N vs 91.9 ± 16.1 N, P < 0.05), whereas there was no significant difference at 24 months after surgery (101.6 ± 14.9 N vs 106.5 ± 13.7 N, P > 0.05). The VAS-satisfaction scores of patients in the two groups were at a similarly high level (90.5 ± 6.8 vs 88.8 ± 7.3, P > 0.05). There was no complication and no arthroscopic revision in either group until 2-year follow-up.

CONCLUSION

Although abductive force recovery of the hip was delayed, hip arthroscopy combined with endoscopic ITB release addressed hip snapping in patients with both FAI syndrome and ESH, and could get similar functional improvement, pain relief, recovery speed, as well as patient satisfaction compared with the pure hip arthroscopy in FAI syndrome patients without ESH.

Hip Abductor and Peritrochanteric Space Conditions

The hip trochanteric bursa, tendinous insertions of the gluteal muscles, and the origin vastus lateralis make up the main structures of the peritrochanteric space. Greater trochanteric pain syndrome (GTPS) refers to pain generated by one or multiple disorders of the peritrochanteric space, such as trochanteric bursitis, gluteus medius and minimus tendinopathy or tear, and disorders of the proximal iliotibial band. Patients with GTPS might present with associated intra-articular hip pathology, which requires further investigation and appropriate management. Successful midterm outcomes have been reported in patients undergoing surgical treatment of GTPS using an open or endoscopic approach.

Hip Stability May Influence the Development of Greater Trochanteric Pain Syndrome: A Case-Control Study of Consecutive Patients

Background:

Greater trochanteric pain syndrome (GTPS) is thought to relate primarily to tendinosis/tendinopathy of the hip abductors. Previous studies have suggested that certain anatomic factors may predispose one to development of the condition.

Hypothesis:

It was hypothesized that intrinsic acetabular bony stability of the hip is related to the development of GTPS.

Study Design:

Cross-sectional study; Level of evidence, 3.

Methods:

A total of 198 consecutive patients diagnosed with GTPS were compared with 198 consecutive patients without clinical evidence of GTPS. Electronic health records of the included patients were examined; data recorded included patient age, sex, race, and body mass index (BMI). Standing anteroposterior radiographs were evaluated by 2 blinded examiners who measured the Tönnis angle, lateral center-edge angle (LCEA), and acetabular depth/width ratio (ADW) and assessed for the presence of a posterior wall sign. The number of dysplastic measures was recorded for each patient based on published norms. Associations between radiographic and patient variables versus the presence or absence of GTPS were determined. Factors with univariate associations where P < .20 were included in a binary logistic regression model to identify independent predictors of the presence of GTPS.

Results:

There was no difference between groups in terms of age, BMI, or race. There were significantly more women than men in the GTPS group (71% vs 30%; P < .001). Intraclass correlation coefficients were good for the LCEA (0.82) and Tönnis angle (0.82) and poor (0.08) for the ADW. Kappa was moderate for the presence of a posterior wall sign (0.51). An increased Tönnis angle, decreased ADW, and ADW <0.25 were significantly associated with the presence of GTPS. The binary logistic regression model identified an increased Tönnis angle (P < .010) and female sex (P < .001) as independent risk factors for GTPS.

Conclusion:

Based on this preliminary retrospective study, decreased intrinsic acetabular bony stability of the hip may be associated with an increased risk of GTPS.

Prevalence of femoro-acetabular impingement in non-arthritic patients with hip pain: a meta-analysis

PURPOSE

As the prevalence of femoro-acetabular impingement syndrome (FAIS) in symptomatic patients who lack evidence of hip osteoarthritis (OA) remains to be described, the purpose of this study was to calculate the prevalence of FAIS in this patient population.

METHODS

Libraries of PubMed, Embase, and Ovid were systematically reviewed for all studies between 2009 and 2019, investigating femoro-acetabular impingement and hip pain. Level I-IV studies delineating patients with hip pain who do not have OA (Tonnis or Outerbridge grades < three) were included. Demographics, outcomes, radiographic parameters, and criteria were entered into a meta-analysis to calculate the incidence of FAIS in non-arthritic symptomatic hips.

RESULTS

In total, 2264 patients (2758 hips) were included in the pooled analysis. Weighted mean age was 31 years. The incidence of FAIS in patients with no evidence of osteoarthritis but who complain of hip pain is 61% (47.3-74.4%). In total, 1483 hips were diagnosed with FAIS. Of the studies that described the rates of all three of the various subtypes of FAIS in their reports, 37% had a combined-type, 38% had a cam-type, and 25% had a pincer-type FAIS.

CONCLUSION

Femoroacetabular impingement should be suspected in 47 to 74% of patients with hip pain and without arthritis. Physicians must maintain a high index of suspicion for FAIS in young patients presenting with hip pain, as FAIS is a common and treatable condition that, if left alone, may lead to hip degeneration.

Image quality of hip MR arthrography with intra-articular injection of hyaluronic acid versus gadolinium-based contrast agent in patients with femoroacetabular impingement

OBJECTIVE

To compare image quality of magnetic resonance arthrography (MRA) of the hip with intra-articular injection of high-viscosity hyaluronic acid (HA-MRA) versus Gd-based contrast agent (Gd-MRA) in patients with femoroacetabular impingement (FAI).

MATERIALS AND METHODS

Design: single-centre, observational, retrospective, inter-individual, and cross-sectional. FAI patients who underwent HA-MRA (3 mL of high-viscosity HA plus 17 mL of saline) were compared with 37 age- and sex-matched FAI patients who underwent Gd-MRA (20 mL of 2 mmol/L solution of gadopentetate dimeglumine). Two independent blinded radiologists assessed image quality for all sequences (two-dimensional proton density, non-fat-sat axial, fat-sat coronal and sagittal; three-dimensional dual-echo steady state), using a 5-point Likert scale considering separately labrum, cartilage, round ligament, transverse ligament, and capsule. Pearson χ² and Cohen κ were used.

RESULTS

The HA-MRA group was composed of 37 patients (23 males, 14 females; median age 38 years), the Gd-MRA group of 37 patients (21 males, 16 females; median age 38 years), without significant difference for age (p = 0.937) and sex (p = 0.636). Image quality did not differ between the two readers for any structure: labrum (p ≥ 0.340), cartilage (p ≥ 0.198), round ligament (p ≥ 0.255), transverse ligament (p ≥ 0.806), and capsule (p ≥ 0.314). Inter-reader agreement (κ) ranged from 0.785 to 1.000.

CONCLUSIONS

HA-MRA provided an image quality not significantly different from that of Gd-MRA. This may open the possibility of combining MRA and viscosupplementation in one single procedure.

Does low back pain or leg pain in gluteus medius syndrome contribute to lumbar degenerative disease and hip osteoarthritis and vice versa? A literature review

[Purpose] Gluteus medius syndrome is one of the major causes of back pain or leg pain and is similar to greater trochanteric pain syndrome, which also presents with back pain or leg pain. Greater trochanteric pain syndrome is associated with lumbar degenerative disease and hip osteoarthritis. The objective of this review was to demonstrate gluteus medius syndrome as a disease entity by reviewing relevant articles to elucidate the condition. [Methods] Gluteus medius syndrome was defined as myofascial pain syndrome arising from the gluteus medius. We performed a search of the literature using the following keywords: “back pain”, “leg pain”, “greater trochanteric pain syndrome”, “degenerative lumbar disease”, “hip osteoarthritis”, and “gluteus medius”. We reviewed articles related to gluteus medius syndrome and described the findings in terms of diagnosis and treatment based on the underlying pathology. [Results] A total of 135 articles were included in this review. Gluteus medius syndrome is similar as a disease entity to greater trochanteric pain syndrome, which presents with symptoms of low back pain and leg pain. Gluteus medius syndrome is also related to lumbar degenerative disease, hip osteoarthritis, knee osteoarthritis, and failed back surgery syndrome. [Conclusion] Accurate diagnosis of gluteus medius syndrome and appropriate treatment could possibly improve lumbar degenerative disease and osteoarthritis of the hip and knee, as well as hip-spine syndrome and failed back surgery syndrome.

Greater Trochanteric Pain Syndrome: An Intraoperative Endoscopic Classification System with Pearls to Surgical Techniques and Rehabilitation Protocols

Over the past decade, understanding of disorders compromising greater trochanteric pain syndrome (GTPS) has increased dramatically. Nonsurgical treatment options include physical rehabilitation and activity modification, anti-inflammatory as well as biologic injections into the peritrochanteric compartment, and administration of oral analgesics. Multiple open and endoscopic treatment options exist when nonsurgical management is unsuccessful in patients with refractory lateral-sided hip pain, with or without weakness. No true consensus exists within the literature regarding operative techniques of GTPS or postoperative rehabilitation protocols. We present an endoscopic classification system of GTPS with 5 distinct types, which seems to correlate well with preoperative diagnoses and postoperative rehabilitation protocols. The classification system is intuitive, and the corresponding surgical techniques are reproducible for surgeons treating peritrochanteric pathology. Level of Evidence: I (hip); II (extra-articular, impingement).

The use of platelet-rich plasma in the treatment of greater trochanteric pain syndrome: a systematic literature review

This review aims to determine whether platelet-rich plasma (PRP) has any role in improving clinical outcomes in patients with symptomatic greater trochanteric pain syndrome (GTPS). A search of NICE healthcare database advanced search (HDAS) via Athens (PubMed, MEDLINE, CINAHL, EMBASE and AMED databases) was conducted from their year of inception to April 2018 with the keywords: ‘greater trochanteric pain syndrome’ or ‘GTPS’ or ‘gluteus medius’ or ‘trochanteric bursitis’ and ‘platelet rich plasma’ (PRP). A quality assessment was performed using the JADAD score for RCTs and MINORS for non-RCT studies. Five full-text articles were included for analysis consisting of three RCTs and two case series. We also identified four additional studies from published conference abstracts (one RCT and three case series). The mean age in 209 patients was 58.4 years (range 48–76.2 years). The majority of patients were females and the minimum duration of symptoms was three months. Diagnosis was made using ultrasound or MRI. Included studies used a variety of outcome measures. Improvement was observed during the first 3 months after injection. Significant improvement was also noted when patients were followed up till 12 months post treatment. PRP seems a viable alternative injectable option for GTPS refractory to conservative measures. The current literature has revealed that PRP is relatively safe and can be effective. Considering the limitations in these studies, more large-sample and high-quality randomized clinical trials are required in the future to provide further evidence of the efficacy for PRP as a treatment in GTPS.