The impact of bursa repair and steroid injection on lateral trochanteric pain following total hip arthroplasty: a retrospective cohort study

Abstract

Objective:

This study aimed to evaluate the clinical outcomes of preserving and repairing the bursal tissue—rather than excising it—during total hip arthroplasty (THA), and to assess the additional effect of administering a steroid injection into the repaired bursa.

Methods:

Patients who underwent total hip arthroplasty (THA) via a posterior approach were retrospectively reviewed and divided into three groups based on the intraoperative bursal tissue management technique. The first group (PB) included patients who received an intraoperative injection of corticosteroid (40 mg methylprednisolone) and local anesthetic (bupivacaine 5 mg/mL) into the preserved bursa. The second group (BR) consisted of patients who underwent bursal repair without injection. The third group (BE) comprised patients who underwent total excision of the bursa. Clinical outcomes were assessed using the Harris Hip Score (HHS), the Visual Analogue Scale (VAS) for pain during daily activities, and VAS for pain while lying on the ipsilateral hip at 6 and 24 months postoperatively.

Results:

A total of 41 patients (27 females, 14 males) who underwent THA were included in the study. No statistically significant differences were observed between the groups in lateral trochanteric VAS scores during daily activities at both 6 and 24 months postoperatively (P > .05). However, a significant difference was found in VAS scores assessed while lying on the operated side at 6 months, favoring the PB group (P < .001). Additionally, Harris Hip Score (HHS) values were significantly higher in the PB group compared to the other groups at both 6 months (P < .001) and 24 months (P = .006).

Conclusion:

Intraoperative corticosteroid and local anesthetic injection, in addition to bursa repair, may improve early postoperative outcomes and pain relief in patients undergoing THA using the posterior approach, without increasing infection risk.

Level of Evidence:

Level IV, Therapeutic Study.

Highlights

• Preservation and repair of the trochanteric bursa with intraoperative steroid and local anesthetic injection significantly improved pain scores while lying on the operated side at 6 months post-total hip arthroplasty (THA).

• Patients in the bursa preservation and steroid injection group exhibited superior Harris Hip Scores than other groups at both 6 and 24 months.

• This study is the first to evaluate intra-bursal corticosteroid injection combined with repair during THA, offering a novel preventive strategy for lateral trochanteric pain.

• No significant differences were observed in Visual Analogue Scale scores during daily activities among the groups at 6 and 24 months, indicating comparable functionality.

Introduction

Total hip arthroplasty (THA) is one of the surgeries with the highest patient satisfaction.¹ However, lateral trochanteric pain, a complication that may develop after THA, can cause pain and a decreased range of motion, similar to the preoperative period.² It has been reported that the incidence of this pain can be as high as 17% in the early postoperative period.³ Lateral trochanteric pain is a regional pain syndrome characterized by tenderness upon palpation over the greater trochanter and pain in the lateral hip and thigh.⁴ While the pain was etiologically multi-faced, involving gluteal tendon pathologies, iliotibial band tension, meralgia paresthetica, and piriformis syndrome, among others,^5,6 it is largely attributed to inflammation of the trochanteric bursa especially among the patients who had THA because of the scar tissue.⁷

The incidence of trochanteric bursa inflammation after THA was reported to be between 4% and 8%.⁸ With the posterior and lateral approaches to the hip, the trochanteric bursa has to be dissected. Opinions vary regarding the management of the bursa after component placement. While some studies recommend excising the bursal tissue due to its potential as a pain source, others advocate preserving and repairing it because it prevents friction, provides vascularity and promotes tissue healing.^9,10

Corticosteroids have been used for many years in the treatment of trochanteric bursitis and lateral trochanteric pain.^11-14 In the series of Iorio et al,⁷ every single case of trochanteric bursitis occurring after THA resolved upon a combination of non-operative treatments. Before this study, no other reports evaluated the response to the preventive treatment of patients with this complication.

This study investigated the impact of steroid and local anesthetic injection into the bursa to mitigate possible bursal inflammation, as well as the protection and repair of bursal tissue. The hypothesis was that steroid and local anesthetic injections would exert a positive impact on early postoperative pain compared to patients who received bursa repair alone.

Material and methods

This study was conducted after having received the approval of the ethics committee of Kartal Dr. Lütfi Kırdar City Hospital Clinical Research Ethics Committee on July 19, 2023 (No. 2023/514/254/1). Between 2020 and 2021, 167 patients who underwent THA by a single surgeon in the Orthopedics and Traumatology Clinic ofKartal Dr. Lütfi Kırdar City Hospital were retrospectively evaluated. Among them, 67 patients who underwent THA using a posterior approach were identified.

The surgeon initially preferred to excise the bursa; however, over time, he began favoring bursal preservation and repair. More recently, his practice has evolved to include intraoperative steroid and local anesthetic injections following bursal repair. This gradual shift in clinical approach, inspired by recent findings in the contemporary literature,^9,15 served as the conceptual starting point of the present study. Patients with incomplete clinical data, those lost to follow-up, previous ipsilateral hip surgery, history of inflammatory arthritis, metabolic disease, malignancy, or prior corticosteroid injections into the trochanteric region were excluded. Additionally, patients with chronic trochanteric bursitis were excluded, with the diagnosis based on the knowledge outlined by Strauss et al.¹⁶ Although not a diagnostic criterion, the hip x-rays of all patients were reviewed to exclude signs of bony formation, as these were routinely obtained for THA planning. Patients with a leg length discrepancy greater than 1 cm were also excluded, as this could be a potential confounding factor, as noted by Farmer et al.¹⁷ In this study, 41 patients, including 27 women and 14 men, were included. Patients were divided into 3 groups in terms of bursal management: the “PB group” (n = 12), in which steroid and local anesthetic injection was administered in addition to the intraoperative repair; the “BR group” (n = 14), in which only bursa repair was performed, and the “BE group” (n = 15), in which bursa excision was performed (Figure 1). Clinical outcomes were evaluated on VAS during daily activities and when lying on the operated side. Turkish verison of the Harris Hip Score (HHS)⁷ was applied postoperatively at the 6th and 24th months. Although the study was designed retrospectively, postoperative VAS and HHS scores were prospectively recorded during routine clinical follow-up at predefined time points (6 and 24 months). Therefore, the risk of recall bias was minimized. Postoperative femoral lateral offset was compared on pelvic anteroposterior radiographs at 6 months postoperatively in terms of increased lateral offset distance, which may be a different cause of lateral trochanteric pain after THA.⁷ Minor and major complications encountered during follow-up, such as superficial and deep infection, were recorded.

Figure 1.

Flow chart.

Surgical technique

All patients included in this study were operated on under spinal or general anesthesia in the lateral decubitus position. Through a posterolateral approach, the trochanteric bursa was accessed through the skin, subcutaneous, and iliotibial fascia. In groups PB and BR, the bursa was incised longitudinally, to be repaired later. In the BE group, the trochanteric bursa was removed. The external rotator tendons were cut, and a T-shaped capsulotomy was performed. Acetabular and femoral components of the same brand and design were applied to all patients. During closure, first the capsule and then the external rotator tendons were repaired with No. 2-0 Vicryl. The trochanteric bursa repair was done with No. 2-0 Vicryl in group PB and BR (Figure 2). A total of 1 mL of 40 mg/mL methylprednisolone and 1 mL of 0.5% bupivacaine were administered intraoperatively into the repaired bursal tissue using a 26-gauge needle to minimize local retention. During the injection, it was observed that the bursa expanded as expected, and the injected solution remained contained within the bursa without leakage. Fascia and subcutaneous fascia were closed with No. 2-0 Vicryl. The skin closure was performed with staples. A Hemovac drain was placed under the fascia. All patients were mobilized with full weight bearing on the first postoperative day and were subjected to the same exercise program.

Figure 2.

Posterior approach, with the patient lying in the lateral decubitus position. The incised bursa held with forceps (A), the approximation of the incised bursa with forceps and repair of external rotators (B), repair of the bursa with sutures with No. 2-0 Vicryl (C), injection of the bursa with 26- gauge needle.

Data analyses

Statistical analysis was performed using the Statistical Package for Social Sciences (SPSS) Version 23.0 (IBM SPSS Corp.; Armonk, NY, USA). The conformity of continuous variables to normal distribution was checked using the Shapiro–Wilk test and Q-Q plot and histogram graphs. Continuous variables were expressed as median (min-max) and mean ± standard deviation (SD). Categorical variables were presented as frequency and percentage. Mixed repeated measures ANOVA, one-way ANOVA, and Bonferroni post hoc analysis were used to compare continuous variables for parametric data exhibiting normal distribution. The Kruskal–Wallis test was employed for categorical data and data of non-normal distribution. For all analyses, a P < .05 was considered statistically significant. The statistical power of this study exceeded 80%, underscoring its capacity to detect clinically meaningful differences across groups and yield robust, statistically significant findings.

Results

The demographic characteristics of the patients are shown in Table 1. No significant differences were found among the groups regarding age, gender, side of surgery, lateral femoral offset values, and incidence of superficial or deep infections (P > .05) (Table 1). Superficial surgical site infections were observed in 2 patients (4.8%) during the early postoperative period. Both cases were successfully managed with local wound care and short-term oral antibiotic therapy, eliminating the need for intravenous antibiotics, surgical intervention, or hospital readmission. No progression to deep infection or prosthetic joint involvement was observed during follow-up.

Table 1.

Demographic and clinical characteristics of the patients

	Repair, Steroid, and LA (PB) n = 12	Repair (BR) n = 14	Bursa excision (BE) n = 15	P
Age	61.83 ± 7.82	56.42 ± 9.01	59.34 ± 8.06	.217
Gender n (%)
Female	9 (75%)	9 (64.3%)	9 (60%)	.168
Male	3 (25%)	5 (35.7%)	6 (40%)
Side n (%)
Left TKA	6 (50%)	8 (57.1%)	7 (46.7%)	.852
Right TKA	6 (50%)	6 (42.9%)	8 (53.3%)
Femoral lateral offset (cm)	4.23 ± 0.54	4.36 ± 0.47	4.23 ± 0.57	.758
Superficial infection n (%)	1 (8.3%)	1 (7.1%)	0 (0%)	.548
Deep infection n (%)	0 (0%)	0 (0%)	0 (0%)	1.000

Postoperative pain VAS scores and HHS at the 6th and 24th months are presented in Table 2. No significant difference existed between the groups in the mean change in lateral trochanteric pain VAS scores during daily activities at 6 and 24 months postoperatively (P = .075, P = .675) (Table 2). However, a statistically significant improvement in pain scores was observed in all 3 groups (PB [P = .008], BR [P < .001], and BE [P = .003]) in terms of the lateral trochanteric pain VAS scores during daily activities at the 6th and 24th months.

Table 2.

Comparison of postoperative 6th and 24th month clinical outcomes

		Mean (SD) 95% CI			Difference between groups
		Repair & steroid & local anesthetic (PB), n = 12	Repair (BR) n = 14	Bursa excision (BE) n = 15	Total	PB vs. BR	PB vs. BE	BR vs. BE
Lateral trochanteric pain (daily activities, VAS score)	6th month	3.33 (1.23) 2.55-4.11	4.85 (1.91) 3.75-5.96	3.86 (1.76) 2.88-4.84	0.075	0.082	1.000	0.367
	24th month	1.91 (0.66) 1.49-2.34	2.00 (0.78) 1.54-2.45	1.73 (0.96) 1.20-2.26	0.675	1.000	1.000	1.000
Within groups		0.008	<0.001	0.003
Lateral trochanteric pain (lying on the operative side, VAS score)	6th month	2.83 (1.11) 2.12-3.54	5.85 (1.35) 5.07-6.63	5.00 (1.41) 4.21-5.78	<0.001	<0.001	<0.001	0.260
	24th month	1.58 (0.66) 1.15-2.00	1.57 (0.85) 1.07-2.06	1.46 (0.74) 1.05-1.87	0.905	1.000	1.000	1.000
Within groups		0.003	<0.001	<0.001
Harris Hip Score	6th month	86.83 (5.55) 83.30-90.36	81.85 (4.60) 79.19-84.51	77.33 (4.82) 74.66-80.00	<0.001	0.046	<0.001	0.057
	24th month	86.33 (4.33) 83.57-89.08	83.00 (3.74) 80.83-85.16	81.60 (2.84) 80.02-83.17	0.006	0.076	0.005	0.920
Within groups		0.515	0.088	<0.001

At the sixth month post-surgery, a significant difference was found in the VAS scores for lateral trochanteric pain when lying on the operated side between the groups (P < .001). Post hoc Bonferroni analysis revealed significant differences between the PB and BR groups (P < .001), and the PB and BE groups (P < .001), but no significant difference between the BR and BE groups (P = .260). Although there was a statistically significant difference in the average lateral trochanteric pain VAS scores between the groups at the 6th month (P < .001), no statistically significant difference was observed between the groups at the 24th month (P = .905). Intra-group comparison of the lateral trochanteric pain VAS scores when lying on the operative side showed statistically significant improvements in all 3 groups from the 6th to the 24th month (PB [P = .003], BR [P < .001], and BE [P < .001]) (Table 2).

Analysis revealed a significant difference in the mean HHS between the groups at 6 months postoperatively (P < .001). Post hoc analysis indicated a statistically significant difference in the mean HHS between the PB and BR groups (P = .046) and the PB and BE groups (P < .001), but no significant difference between the BR and BE groups (P = .057). At 24 months, a statistically significant difference in the mean HHS was observed between the groups (P = .006). Post hoc analysis showed a significant difference between the PB and BE groups (P = .005) but no statistically significant differences between the PB and BR (P = .076) and the BR and BE (P = .920) groups (Table 2). Comparison of the HHS at the 6th and 24th months exhibited no statistically significant difference between the PB (P = .515) and BR (P = .088) groups, while a statistically significant improvement in the HHS was noted in the BE group (P < .001) (Table 2). This finding proved that the early improvement in the PB group was attributed to the corticosteroid effects.

Discussion

The hypothesis was confirmed that intraoperative administration of corticosteroids and local anesthetics into the repaired trochanteric bursa effectively reduces lateral trochanteric pain in the early postoperative period for patients who underwent THA via the posterior approach. A significant improvement was observed in the HHS at the 6th- and 24th-month follow-ups. Notably, the administration of local steroids did not increase infection risk.

In a prospective study by Chalidis et al⁹ involving 40 patients, the effects of trochanteric bursa repair vs. excision on clinical outcomes were compared. The study reported earlier recovery in patients who underwent bursa repair, with improved pain scores when lying on the hip in the early period, although daily activity scores were similar between the bursa repair and excision groups. By the third postoperative month, clinical outcomes were comparable in both groups. This study found that the addition of steroids and local anesthetics to bursa repair positively influenced pain Visual Analog Scale (VAS) scores and HHS in the early postoperative period; however, it did not significantly impact VAS scores for daily activities.

Conversely, some studies suggest that excision of the bursa may migitate postoperative trochanteric bursitis, thereby preventing lateral trochanteric pain. In a retrospective study by Teng et al⁸ involving 954 patients who underwent THA for primary osteoarthritis between 2010 and 2020, no significant difference was observed in postoperative bursitis development between groups with and without bursa excision.

Alkan et al,¹⁷ in a retrospective study of 98 patients, investigated factors contributing to lateral trochanteric pain after THA. They concluded that bursa repair is not associated with lateral trochanteric pain development, attributing this to the trochanteric bursa’s role as a cushion for more posterior structures rather than the lateral structures, such as external rotators. Firat et al¹⁸ examined the development of deep gluteal syndrome in groups with and without bursa repair. They found a higher frequency of deep gluteal syndrome in the group without repair, although clinical scores were similar between both groups.¹⁹ In this study, BR and BE groups (without steroid injection) showed no significant difference in VAS and HHS scores. While the BE group exhibited the greatest increase in HHS score between 6 and 24 months, the average HHS score at the 24th month was the lowest in the BE group compared to the other groups. It was significantly lower than in the PB group.

Increased femoral offset has been identified as a cause of lateral trochanteric pain following THA. Worlicek et al¹⁹ reported that femoral offset restoration significantly reduced postoperative trochanteric pain syndrome and improved clinical outcomes. Conversely, Iorio et al⁷ reported no significant relationship between femoral offset and the incidence of lateral trochanteric pain. To assess the potential impact of lateral offset, offset distances were compared between the groups and observed no significant differences, thereby strengthening the study’s validity.

In managing trochanteric bursitis, treatment modalities include physical therapy, non-steroidal anti-inflammatory drugs, local corticosteroid injection, extracorporeal shockwave therapy, and endoscopic or open bursa excision. Although the positive effects of corticosteroid injections on clinical outcomes are well-documented in both THA and non-THA patients, this study was the first to evaluate the impact of intra-bursal injection combined with bursa repair during THA surgery.^20,21 As in this study, the early VAS and HHS scores of the PB group support the theory of preventive usage of corticosteroids in lateral trochanteric pain.

Nonetheless, this study has several limitations, such as a small sample size and retrospective design, which may limit its generalizability and introduce potential selection bias. Additionally, the absence of uniformly recorded preoperative VAS and HHS scores, particularly in the conservatively managed group, prevented statistical assessment of baseline comparability between groups. Furthermore, although no infection-related complications were observed following intraoperative steroid injection in the cohort, the small sample size constrains the robustness of this conclusion, and caution is warranted when interpreting the infection-related outcomes. The absence of long-term follow-up beyond 24 months is another limitation that hinders a comprehensive understanding of the sustained effects of different bursa management strategies on patient satisfaction and hip function. Further studies should address these pitfalls by involving larger patient cohorts, prospective randomized controlled trials, and longer follow-up periods to confirm the results and long-term sequelae. Wearing down the effects of surgical technique, patient comorbidities, and postoperative rehabilitation protocols is also necessary to clearly define the effect of bursa repair and steroid injection on lateral trochanteric pain.

In the near future, a prospective study with a larger sample and a longer follow-up will be required to guide an extended application of strategies in bursa management. Exploring the molecular and biomechanical mechanisms underlying the clinically observed improvements may elucidate the contribution of steroid and anesthetic injections to pain alleviation and functional results. This may allow more targeted and efficient interventions to be implemented in the management of lateral trochanteric pain after THA for better patient outcomes and satisfaction.

In patients who underwent THA through the posterior approach, intraoperative administration of steroid and local anesthetic in addition to trochanteric bursa repair exerted a positive effect on pain scores and patient outcomes in the early period, and similar clinical results were observed as the follow-up period was extended. Steroid administration did not increase infection rates.

Funding Statement

The authors declared that this study has received no financial support.

Data availability statement:

The datasets generated and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Supplementary material

Power Analysis for the Harris Hip Score

A post hoc power analysis was conducted for the Harris Hip Score using the F-test family, specifically the repeated measures ANOVA with a within-between interaction model. The achieved power (1-β error probability) was calculated to be 1.000. The analysis included a total sample size of 41 patients, with three groups and two time points of evaluation. The correlation among repeated measures was assumed to be 0.5, and the nonsphericity correction (ε) was determined to be 1.000 based on Mauchly’s Test of Sphericity. The partial eta squared (η²) was calculated using the sum of squares values for the effect (676.038) and the error (1292.157), resulting in an effect size of 0.34.