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Editorial Commentary: Hip Trochanteric Bursitis and Femoroacetabular Impingement: The Arthroscope Is Only the Tool
Editorial Commentary: Hip Trochanteric Bursitis and Femoroacetabular Impingement: The Arthroscope Is Only the Tool Nicola Maffulli, M.D., M.S., Ph.D., F.R.C.P., F.R.C.S.(Orth)
Abstract: Lateral hip pain is debilitating, with pain located at or around the greater trochanter, and trochanteric bursitis is one of the conditions that are part of the greater trochanter pain syndrome. At times, trochanteric bursitis coexists with femoroacetabular impingement. In such cases, the arthroscope is used as a soft tissue endoscope facilitating debridement of the bursa and functional lengthening of the fascia lata. Coupled with appropriate femoroacetabular impingement treatment and rehabilitation, the procedure allows predictable functional results.
See related article on page 1455
L
ateral hip pain is debilitating, with pain located at or around the greater trochanter, which is the site of confluence of 3 bursae, the hip abductor-lateral thigh muscles, and the iliotibial tract. Advanced imaging and surgical findings in patients with pain and tenderness of the greater trochanter region, buttock and lateral thigh, have evidenced disorders involving incomplete tearing or avulsion of the anterior aspect of the gluteus medius and gluteus minimus tendons, external snapping hip, and enthesiopathy.1 As Vap, Mitchell, McNamara, Briggs, and Philippon report in “Outcomes of Arthroscopic Management of Trochanteric Bursitis In Patients With Femoroacetabular Impingement: A Matched Comparison of Two Patient Groups,”2 trochanteric bursitis is one of the conditions that are part of the greater trochanter pain syndrome; it induces diagnostic uncertainty, exerts a marked negative impact on patients’ life, and can be resistant to even well-performed and prolonged conservative management. At times, as in the patients studied in this investigation, the whole picture can be complicated by the co-existence of intra-articular pathology, such as femoroacetabular impingement.3,4 At this point, I believe, one has to
University of Salerno The author reports that he has no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Ó 2018 by the Arthroscopy Association of North America 0749-8063/1816/$36.00 https://doi.org/10.1016/j.arthro.2018.01.004
couple both clinical suspicion and acumen with great diagnostic accuracy to produce a suitable diagnosis. Only at this point can exceptional technical prowess be paired with great professionalism allowing the superior skills of a master arthroscopist to come into play. It has become a relatively easy task to stick an arthroscope in a patient’s hip and repair, restore, debride, remove, and generally bring benefit to our patients, though to be an expert implies quite a bit more than just producing a few stab wounds. The arthroscope is but a tool; over the course of the last several years it has been realized that we are not to be limited by the lack of an articular cavity to be able to ply our trade. We are limited only by our imagination, and stimulated by our wish to progress and benefit our patients. In this particular instance, it is evident that some patients with femoroacetabular impingement may also have extra-articular pathology. Obviously, to address only one problem (the femoroacetabular impingement) would leave the patient short, and induce in us sleepless nights. The group led by Mark Philippon shows that old style procedures work extremely well using new ideas and concepts and novel technical skills. I was taught by one of my old trainers, Mr. Douglas Wardlaw, ChM, FRCSEd, in Aberdeen, Scotland, to debride, in an open fashion, the bursa and perform either a longitudinal tenotomy of the fascia lata over the greater trochanter, or the cruciform incision that the Vail’s group favors. At the time, we undertook the procedure in an open fashion; now we use endoscopic techniques.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 34, No 5 (May), 2018: pp 1461-1462
1461
1462
EDITORIAL COMMENTARY
The work described here hypothesizes that patients with femoroacetabular impingement would likely develop trochanteric bursitis as a consequence of their intraarticular hip pathology, which would induce altered gait mechanics and pelvic muscular imbalance.2 We do not know whether this is actually true, but it does make sense. The operation would not work just removing some pathological tissue; it would functionally rebalance the lower limb muscles, and allow us to break the vicious circle of pain, functional imbalance, and further pain with the use of appropriate rehabilitation. Surgery, even minimally invasive surgery, is but the very tip of the iceberg, and accurate physiotherapy should follow to optimize results.4 It appears that in Vail they got the recipe right!
References 1. Del Buono A, Papalia R, Khanduja V, Denaro V, Maffulli N. Management of the greater trochanteric pain syndrome: a systematic review. Br Med Bull 2012;102:115-131. 2. Vap AR, Mitchell JJ, Briggs KK, McNamara SC, Philippon MJ. Outcomes of arthroscopic management of trochanteric bursitis in patients with femoroacetabular impingement: A comparison of two matched patient groups. Arthroscopy 2018;34:1455-1460. 3. Longo UG, Franceschetti E, Maffulli N, Denaro V. Hip arthroscopy: State of the art. Br Med Bull 2010;96:131-157. 4. Papalia R, Del Buono A, Franceschi F, Marinozzi A, Maffulli N, Denaro V. Femoroacetabular impingement syndrome management: Arthroscopy or open surgery? Int Orthop 2012;36:903-914.
Abstract: Lateral hip pain is debilitating, with pain located at or around the greater trochanter, and trochanteric bursitis is one of the conditions that are part of the greater trochanter pain syndrome. At times, trochanteric bursitis coexists with femoroacetabular impingement. In such cases, the arthroscope is used as a soft tissue endoscope facilitating debridement of the bursa and functional lengthening of the fascia lata. Coupled with appropriate femoroacetabular impingement treatment and rehabilitation, the procedure allows predictable functional results.
See related article on page 1455
L
ateral hip pain is debilitating, with pain located at or around the greater trochanter, which is the site of confluence of 3 bursae, the hip abductor-lateral thigh muscles, and the iliotibial tract. Advanced imaging and surgical findings in patients with pain and tenderness of the greater trochanter region, buttock and lateral thigh, have evidenced disorders involving incomplete tearing or avulsion of the anterior aspect of the gluteus medius and gluteus minimus tendons, external snapping hip, and enthesiopathy.1 As Vap, Mitchell, McNamara, Briggs, and Philippon report in “Outcomes of Arthroscopic Management of Trochanteric Bursitis In Patients With Femoroacetabular Impingement: A Matched Comparison of Two Patient Groups,”2 trochanteric bursitis is one of the conditions that are part of the greater trochanter pain syndrome; it induces diagnostic uncertainty, exerts a marked negative impact on patients’ life, and can be resistant to even well-performed and prolonged conservative management. At times, as in the patients studied in this investigation, the whole picture can be complicated by the co-existence of intra-articular pathology, such as femoroacetabular impingement.3,4 At this point, I believe, one has to
University of Salerno The author reports that he has no conflicts of interest in the authorship and publication of this article. Full ICMJE author disclosure forms are available for this article online, as supplementary material. Ó 2018 by the Arthroscopy Association of North America 0749-8063/1816/$36.00 https://doi.org/10.1016/j.arthro.2018.01.004
couple both clinical suspicion and acumen with great diagnostic accuracy to produce a suitable diagnosis. Only at this point can exceptional technical prowess be paired with great professionalism allowing the superior skills of a master arthroscopist to come into play. It has become a relatively easy task to stick an arthroscope in a patient’s hip and repair, restore, debride, remove, and generally bring benefit to our patients, though to be an expert implies quite a bit more than just producing a few stab wounds. The arthroscope is but a tool; over the course of the last several years it has been realized that we are not to be limited by the lack of an articular cavity to be able to ply our trade. We are limited only by our imagination, and stimulated by our wish to progress and benefit our patients. In this particular instance, it is evident that some patients with femoroacetabular impingement may also have extra-articular pathology. Obviously, to address only one problem (the femoroacetabular impingement) would leave the patient short, and induce in us sleepless nights. The group led by Mark Philippon shows that old style procedures work extremely well using new ideas and concepts and novel technical skills. I was taught by one of my old trainers, Mr. Douglas Wardlaw, ChM, FRCSEd, in Aberdeen, Scotland, to debride, in an open fashion, the bursa and perform either a longitudinal tenotomy of the fascia lata over the greater trochanter, or the cruciform incision that the Vail’s group favors. At the time, we undertook the procedure in an open fashion; now we use endoscopic techniques.
Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 34, No 5 (May), 2018: pp 1461-1462
1461
1462
EDITORIAL COMMENTARY
The work described here hypothesizes that patients with femoroacetabular impingement would likely develop trochanteric bursitis as a consequence of their intraarticular hip pathology, which would induce altered gait mechanics and pelvic muscular imbalance.2 We do not know whether this is actually true, but it does make sense. The operation would not work just removing some pathological tissue; it would functionally rebalance the lower limb muscles, and allow us to break the vicious circle of pain, functional imbalance, and further pain with the use of appropriate rehabilitation. Surgery, even minimally invasive surgery, is but the very tip of the iceberg, and accurate physiotherapy should follow to optimize results.4 It appears that in Vail they got the recipe right!
References 1. Del Buono A, Papalia R, Khanduja V, Denaro V, Maffulli N. Management of the greater trochanteric pain syndrome: a systematic review. Br Med Bull 2012;102:115-131. 2. Vap AR, Mitchell JJ, Briggs KK, McNamara SC, Philippon MJ. Outcomes of arthroscopic management of trochanteric bursitis in patients with femoroacetabular impingement: A comparison of two matched patient groups. Arthroscopy 2018;34:1455-1460. 3. Longo UG, Franceschetti E, Maffulli N, Denaro V. Hip arthroscopy: State of the art. Br Med Bull 2010;96:131-157. 4. Papalia R, Del Buono A, Franceschi F, Marinozzi A, Maffulli N, Denaro V. Femoroacetabular impingement syndrome management: Arthroscopy or open surgery? Int Orthop 2012;36:903-914.