Introduction

The bump of bone on the outside of the hip bone is called the greater trochanter. When the tissue or bursa in this area becomes thickened and inflamed causing pain, surgery may be needed to remove the bursa and to reduce tension on the tendon that glides over it.

Where friction must occur between muscles, tendons, and bones there is usually a structure called a bursa. A bursa is a thin sac of tissue that contains a bit of fluid to lubricate the area where the friction occurs. The bursa is a normal structure, and the body will even produce a bursa in response to friction.

The trochanteric bursa lies over the greater trochanter of the hip, the bump on the outer part of the femur. The gluteus maximus is the largest of three gluteal muscles of the buttock. This muscle spans over the side of the hip and joins the iliotibial band. This long tendon passes over the bursa on the outside of the greater trochanter, runs along the side of the thigh, and attaches just below the outside edge of the knee.

Walking causes the gluteus maximus to pull on the tendon. If the tendon is tight, it will start to press and rub against the greater trochanteric bursa. It is unclear why the tendon becomes tight. The rubbing causes friction to build in the bursa, leading to irritation and inflammation in the bursa.

Friction can also start if the outer hip muscle (gluteus medius) is weak, if one leg is longer than the other, or if you run on banked surfaces.

Rationale

Surgery is indicated for this condition only after conservative treatments have failed including anti-inflammatory medications, cortisone injections and physical therapy. The primary goal of surgery is removing the thickened bursa, removing any bone spurs (knobby outgrowths) that may have formed on the greater trochanter, and relaxing the large tendon of the gluteus maximus. Some surgeons prefer to simply lengthen the tendon a bit, and some prefer to remove a section of the tendon that rubs directly on the greater trochanter. Both procedures result in taking pressure off the bursa.

Surgical Procedure

Before surgery begins, you will be given anesthesia. There are two basic options: a general anesthetic (one that puts you to sleep) or a regional block (one that numbs the area to be worked on). For hip surgery the most common type of regional anesthetic available is either a spinal block or an epidural block. Both of these regional blocks numb the body from the waist down.

An incision is made in the side of the thigh over the area of the greater trochanter. The surgeon continues the incision through the tissues that lie over the bursa. 

The tendon is split so the trochanteric bursa and the bone of the greater trochanter can be seen. The tendon is split lengthwise.

The surgeon then removes the bursa sac.

The bone of the greater trochanter is smoothed, and any bone spurs are removed. 

At this point the tendon may be lengthened or released and not repaired. If the surgeon chooses not to repair the tendon, scar tissue will eventually heal the loose edges of the tendon. As it heals, it will be looser than before surgery, so it won't rub on the greater trochanter quite so much. The skin is closed with stitches.

As with any major surgery, complications are possible during the operation and after. Some of the most common complications following surgery for trochanteric bursitis are infection, nerve or blood vessel injury, and failure of the operation.

After Surgery

After surgery, your hip will be covered over with a padded dressing. You will probably be advised to avoid a great deal of activity within the first week after surgery. Support your outer hip with a pillow when you sit or recline. During this time, you may also be instructed to use crutches to keep from placing weight on your hip while standing or walking. Your stitches will be removed ten to fourteen days after surgery. If your surgeon chooses to use dissolvable stitches, these will not need to be removed. 

Rehabilitation

Rehabilitation after surgery can be a slow process. You will probably need to attend therapy sessions for several weeks, and you should expect full recovery to take several months. Getting the hip moving as soon as possible is important. However, this must be balanced with the need to protect the healing muscles and tissues.

Ice and electrical stimulation treatments may be used during your first few physical therapy sessions to help control pain and swelling from the surgery. Your therapist may also use massage and other hands-on treatments to ease muscle spasm and pain.

Treatments include range-of-motion exercises and gradually work into active stretching and strengthening. Active therapy starts two to three weeks after surgery. You may begin with light isometric strengthening exercises. These exercises work the muscles without straining the healing tissues.

At about four weeks you may start doing more active strengthening. Exercises focus on improving the strength and control of the buttock and hip muscles. Your therapist will help you retrain these muscles to keep the ball of the femur moving smoothly in the socket.

Some of the exercises you'll do are designed get your hip working in ways that are similar to your work tasks and sport activities. Your therapist will help you find ways to do your tasks that don't put too much stress on your hip. Before your therapy sessions end, your therapist will teach you a number of ways to avoid future problems.