YGC -Journal club ICS Team 29.4.2013

1. YGC -Journal clubICS Team29.4.2013

2. 1 review article + 2 studies+1 new technique • Introduction • Review article • Paper 1 • Paper 2 • New technique • Q&A

5. GTPS Greater trochanteric pain syndrome • Incidence 10-25 % • Stegemann 1923 – ‘Trochanteric bursitis’ • Syndrome – Leonard JAMA 1958 • Pain and reproducible tenderness - Gr. trochanter,buttock,lateral thigh

6. Anatomy • Sub G Maximus and Sub G Medius • Variable occurrence of bursae • Unpredictable referral pain patterns • Buttock Groin Low back • Frequent misdiagnosis,inadequate response to injections

7. E’logy&Associations • 10-20% over 60 • UK ??,US 1.8/1000 • Obese woman with back pain & hip OA&short leg • Vectors around the hip altered

8. Mechanism • Trauma overuse Obesity • ~92% had OA hip, RA ,LS OA • c/c microtrauma,regional ms dysfunction • Inflammation of G medius,GMedius/F Lata • Ac trauma crstal deposition TB • Caution r/o stress # and AVN

10. Evaluation • Pain – lateral hip or buttock - exacerbated by differing postures Physical exam – jump sign • Resistance to abduction and ext rotation • No pain on extension ~ intra art pathology

11. Where is the pain ?

12. Diffentials - ITB Syndrome – Ober’s test -Meralgia paresthetica

13. Treatment • Conservative • NSIADS Ice Physio Wt loss Behaviour modification Flexibility,Ms strengthening • Injections • Arthroscopic bursectomy • ITB lengthening • Osteotomies

14. Summary of paper • Authors • Aim of study • Methods used (including randomisation process if RCT, etc) • Statistics • Results • Conclusions

15. Critique • Level of Evidence • Did the authors accomplish their aim? • Did the evidence support their conclusions? • Methods • Any bias? (Selection/Treatment/Evaluation/Spectrum/Observer etc) • Power of study acceptable? • Any flaws in methodology? • Loss to follow-up etc? • Any improvements to study design possible? • Appropriate statistics used for study? • Appropriate analysis of results?

16. Conclusions • Conclusion about quality of study • Implications for current practice

18. No 1

19. Summary of paper • Authors • Aim of study • Methods used (including randomisation process if RCT, etc) • Statistics • Results • Conclusions

20. Summary of paper • Karpinsky and Piggott – JBJS Br 1985 • 6 year study new patients ( 12-59 y Ave 43 y) • Retrospective review • 15 patients with Trochanteric pain • 11 F / 4 M • 12 had Full ROM hip/3had back pain • Radiographs 12 Normal /3 Calcification • 12 Steriod,2US,1 no mention • Important to diagnose – treatment helps outcome

21. No 2

22. Summary of paper • Peter Walker et al CORR 2006 • Does imaging predict response to injection • Prospective ,97 pts 3 year period • Inclusions lat hip pain ,presumed dx Trochanteric bursitis,rx with physio,NSAIDs

23. Summary of paper • Excluded Traumatic cases,prev injection, spinal sx • Statistics • 74 F/23M Ave - 58 (23-74y) - 4 younger than 50 • MRI Hip 78 • CT LS spine 42 • 3 phase bone scan hip pelvis and l spine • SPEC T to evaluate spine disorders

24. Summary... • History Phys exam + Investigations • Response to injection • Trochanteric bursitis –GT hyperemia and uptake at post aspect of GT • G medius tendinitis-Lateral and ant hyperemia + uptake lateral and anterior • Zygapophyseal disease - SPECT

25. Stats • Binary logistic regression • Fischer exact test • Results -Scintigraphic criteria + P V 90% / -P V97% -Inter obs reproducibility kappa value .82

26. 97 pts -12 Bilateral • Symptoms dur Ave 4.8months (3wks-9Mo) • 75/97 back pain ! ( 74/97 Scinti evidence) • Scintigraphic 84 ( none 13) • 4 Multi level discs /10 other probs

27. Could any variable predict response to injection ? • 48 Injections. • 18 recurrent pain in 6 weeks

28. Analysis • Spinal disease predicted recurrent symptoms

30. A new technique for Trochanteric bursitis • Govaert A M C Amsterdam JBJS Br 2003 • 10 patients ( 12 hips ) • Salvage procedure for a pt who already had bursectomy and IT band surgery • 1994-2000 • 12 hips • 10 F/2 M • 28-73 Y (48.3Y)

31. A new technique for trochantric bursitis • Pain on awakening got worse limiting ADLs • Full ROM,10 limp,1 used a stick ,1 crutches • Tender GT • Radiographs no abnormalities • One year NSAIDs Physio,Injection, heel raise – NO EFFECT • Mean dur Rx 4 years • Mean no of injectiosn 3

32. A new technique for trochantric bursitis • 5 Bursectomy fenestration • One 2 surgeries • Pain recurred 6.3 months(1-23 Mo)

33. Surgery • Osteotomy of trochanter • 5-10 mm slice of trochanter • Reattached distal and medial 2 4.5 screws

34. Post op

35. Results • F U 6-77 Mo (23.5Mo) • Mean score inproved 15.8-27.5

36. Conclusions • Repetitive friction • Conservative 90 % Why effective ? -reduction of trochanter height -increase stregth of AbDuctors -post op hyperemia