14. greater trochanteric pain syndrome
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Greater Trochanteric Pain Syndrome: Who Benefits From Surgery and How Do I
Interpret MRI? Joshua Harris, MD August 16, 2015
Disclosures: CommiLees: AAOS OAFP Workgroup, AOSSM Self-‐Assessment Editorial board: Arthroscopy, Fron;ers in Surgery PublicaOon royalOes: SLACK, Inc.
• Greater trochanteric pain syndrome • Peritrochanteric pain syndrome • Lateral hip pain syndrome • Trochanteric bursiOs
GTPS
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Not GTPS
Abductor Anatomy
Bursa Anatomy – Is It Really “BursiOs”?
• 18 hips • Average: 6 bursae per hip
• As many as 4 bursae under gluteus maximus and fascia lata • “Trochanteric” bursa
• Usually 2 bursae under gluteus medius • Usually 1 bursa under gluteus minimus
• All bursae were synovial lined • All but two of the bursae are located anterior to trochanteric apex
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Bursa Anatomy – Is It Really “BursiOs”?
Right hip, prone
Bursa Anatomy – Is It Really “BursiOs”?
Right hip, prone
Bursa Anatomy – Is It Really “BursiOs”?
Right hip, prone
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• Chronic, oZen atraumaOc lateral hip pain – Females > Males – >40 years of age – Night pain – Limp
• Exam: – Trendelenburg gait, abductor lurch – Single leg stance test (>2 cm) – Lateral tenderness – Abductor weakness
GTPS PresentaOon
• GTPS • Abductor tendon tear • External coxa saltans • Superior gluteal nerve injury • Lumbosacral • Abductor faOgue / dysplasia • Intra-‐arOcular (OA, FAI, labrum, Fx)
Lateral Hip Pain DifferenOal Diagnosis
• Plain radiographs • Ultrasound • MRI
Imaging EvaluaOon
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• Arthrogram unnecessary • Prefer 1.5-T, 3.0-T magnet with surface coil
– Improved resolution
• Both fluid- and fat-sensitive imaging series – Coronal, axial, sagittal
MRI EvaluaOon
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Piriformis
ITB / fascia lata
Gluteus medius
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Gluteus minimus
Capsule
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• Grading – 0: 0 – I: 15 – II: 8 – III: 2 – IV: 5
Goutallier ClassificaOon
• Highly reliable, responsive • Increased preop faLy
infiltraOon correlated with: – Increased post-‐op pain – Decreased HOS-‐ADL, HOS-‐SSS – Decreased paOent saOsfacOon
• 2 failures (gluteus max transfer)
Goutallier ClassificaOon
Normal
Goutallier ClassificaOon
FaLy streaks
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Goutallier ClassificaOon
FaLy infiltraOon with muscle > fat
Goutallier ClassificaOon
FaLy infiltraOon with muscle = fat
Goutallier ClassificaOon
FaLy infiltraOon with fat > muscle
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• IniOal non-‐surgical management x 6 weeks – Oral NSAIDs – Bursal injecOons (corOsone, PRP)
• Mautner, et al. 2013 PM R. • PRP – 81% subjects had moderate to complete relief of symptoms for tendinopathy and parOal tear gluteus medius
– Physical therapy • Core, lumbar spine, hip, lower extremity
Who Benefits From Surgery?
• 8 studies, all level IV, 94% female, 18 mo follow-‐up – 135 open, 35 endoscopic – 71% gluteus medius, 29% medius + minimus
• Significantly improved mHHS for both (p > 0.05) • Re-‐tear rate:
– 9% open – 0% endoscopic
Open vs Endoscopic Abductor Repair
Conclusions
• Greater trochanteric pain syndrome encompasses a spectrum of pathology for lateral sided hip pain
• There are mulOple bursae culprit for bursiOs • Index of suspicion for abductor tendon pathology
– MRI if concerned for tendon tear – Open or endoscopic highly successful – “Hug” test
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