Introduction
Several bursae surround the greater
trochanter of the femur. Two bursae that lie between the gluteus maximus
muscle and the greater trochanter are thought to be of greatest clinical
significance. The superficial bursa is immediately beneath the gluteus
maximus over the lateral surface of the greater trochanter. Beneath the
superficial bursa, is the appropriately named deep
bursa. The deep bursa is larger and blankets the
"cuff " of tissue around the greater trochanter formed by
the attachment of the gluteus medius (posteriorly), gluteus minimus
(anterolaterally), and vastus lateralis (anteriorly).
Although the term bursitis suggests that the primary pathology is
inflammation at one or more of the peritrochanteric bursae, recent
magnetic resonance imaging (MRI) evidence indicates that the majority of
patients with clinical findings consistent with the diagnosis of
trochanteric bursitis have tendinosis, or a partial or complete tear of
the gluteus medius or minimus as their primary pathology, not
trochanteric bursae inflammation. Current theory holds that gluteal
tendinosis induces muscle atrophy, femoral head subluxation, and
bursitis in the contiguous bursae and that subsequent impingement of the
distended bursae results in painful range of motion. Regardless of the
associated pathology, injection at the trochanter is often successful in
treating symptoms. Most (61%) patients report improvement at 6
months following trochanteric bursa injection.
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Leg length discrepancy, tight
iliotibial band, arthritis of the hip, obesity, and lumbar spondylosis
may be predisposing factors for the development of trochanteric
bursitis. Once lumbar spine, hip, and other pathology have been
excluded, the clinical presentation is usually sufficient to make a
presumptive diagnosis. Patients complain of localized, lateral hip pain
that is often worse when lying on the affected side at night. On
examination, there is focal tenderness to palpation, and occasionally
swelling, at the greater trochanter.
The differential diagnosis of hip pain
includes osteoarthritis of the hip, iliotibial band syndrome, and
adductor tendenopathy.
Equipment
- Syringe, 10 mL.
- Needle (22 " 25
gauge, 1.5 inches) on a 10-mL syringe (consider a longer needle
for the obese patient). - Methylprednisolone acetate (40 mg
Depo-Medrol; 1 mL if 40 mg/mL). One mL of 40 mg/mL triamcinolone
acetonide (Kenalog) is a reasonable
alternative to Depo-Medrol but may carry a higher risk of
atrophy than Depo-Medrol. - 1% " lidocaine (5 mL) without epinephrine.
- Consult the ordering
information that appears in Appendix I. Needles,
syringes, and corticosteroid preparations may be ordered from
surgical supply houses or local pharmacies. A suggested tray for
performing soft tissue aspirations and injections is listed in Appendix
I. Skin preparation recommendations appear in Appendix
E.
Indications
- Symptomatic discomfort
at the greater trochanter of the hip
Contraindications
- Drug allergy to
injectable materials - Infection: septic
arthritis, bacteremia, or cellulitis at the injection site - Minimal relief after
prior injections (relative) - Underlying coagulopathy
or uncontrolled anticoagulation (relative) - Uncontrolled diabetes
(relative) - Joint prosthesis
(scarring changes anatomy; foreign body increases risk for
infectious complications) (relative)
The Procedure
Step 1
After informed consent is
obtained, hands are washed, materials are prepared, and gloves are
applied. Position the patient in the lateral recumbent position with
the affected side up.
Step 1 View Original Step 1 View Original
Step 2
Identify the point of
maximal tenderness, and mark the site with a pressure mark from a
needle cap, pen, or fingernail.
Step 2 View Original Step 2 View Original
Step 3
Swab the patient 's
skin with povidone-iodine, chlorhexidine solution, or 70%
ethanol. (See Appendix E.) Do not touch the injection site after
swabbing.
Step 3 View Original Step 3 View Original
Step 4
Insert the needle
perpendicular to the skin and advance until the needle tip touches
the bone. Withdraw the needle 2 to 3 mm, then aspirate and inject
the steroid and lidocaine mixture. Have patient rest in the
office for 20 to 30 minutes postinjection to ensure the patient
tolerates the procedure and to review postprocedure
instructions.
- PEARL: Maximal tenderness is often found
at the muscle insertions along the superior and posterior
borders of the greater trochanter. This may require larger
injection volumes and/or a fanned technique to disperse the
medication to the deep bursae, which superficially blankets
the tendons described previously. - PITFALL: Long-acting, low-solubility,
fluorinated glucocorticoids (such as triamcinolone
hexacetonide [Aristospan]) are
considered inappropriate for soft tissue injections by some
authors because of a higher risk of tissue atrophy. Triamcinolone
acetonide (Kenalog) is a fluorinated triamcinolone, but solubility is
intermediate to high. This makes Kenalog a reasonable
alternative for this procedure but it may carry a higher
risk of tissue atrophy than methylprednisolone.
Step 4 View Original Step 4 View Original
Complications
Local Effects
- Local
infection (reported incidence range 1:3,000 to
1:50,000). - Local
reactions (swelling, tenderness, and warmth for up to 2
days). - Steroid flare
(1% to 10%; crystal-induced synovitis within
24 to 48 hours). - Fat atrophy
(especially at superficial soft tissue sites; worse with triamcinolone because it is less
soluble and is fluorinated). - Damage to
local cartilage or nerves.
Systemic Effects
- Facial
flushing (<15% of patients; within hours;
lasts <3 or 4 days; women) - Adrenal
suppression (usually mild and transient; worse with
stress) - Transient
increase in glucose
Pediatric Considerations
Trochanteric bursitis is rarely seen
in children.
Postprocedure Instructions
Cover the injection site with a
bandage. Ask the patient to gently move the area to spread the injected
fluid. Advice about rest and timing between repeat injections is
variable. Generally, avoiding aggravating activities for 24 hours is
sufficient in this situation. Although evidence-based studies are
lacking, general recommendations advise a respite of 6 weeks between
injections and no more than three to four injections into the same
region within a given year.
Coding Information and Supply Sources
View Large CPT Code Description 2008 Average 50th Percentile Fee Global Period 20610 Arthrocentesis, aspiration, and/or injection of large joint
or bursa $ 176.00 0 CPT is a registered trademark of the American
Medical Association.2008 average 50th Percentile Fees are provided courtesy of 2008
MMH-SI 's copyrighted Physicians ' Fees and
Coding Guide.
ICD-9 Code
Trochanteric bursitis
726.5
Bibliography
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Evidence-based soft tissue rheumatology III:
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Diagnostic and therapeutic injection of the
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Phys.
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"trochanteric
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